Interval Health History For Athletics @ Fort Ann Central School
This form is required by NYS for each athletic season. This form must be completed by a parent/legal guardian.
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Student Name: *
Name of Parent/Guardian Completing this Form: *
Current Sport Season *
Student's Current Grade: *
Has your child ever been restricted by a health care provider from sports participation for any reason? *
Does your child wear glasses or contact lenses? *
Is your child prescribed an Epi-Pen for a life threatening allergy? *
Does your child have food allergies? *
Does your child have an ongoing medical condition *
Has your child ever been diagnosed with a concussion, or experienced concussion symptoms (dizziness, fatigue or confusion after a hit to the head)? *
Does your child use a brace, orthotic or other device? *
Has your child ever experienced shortness of breath, cough or wheezing during exercise? *
Does your child use an inhaler for asthma? *
Has your child ever fainted or felt lightheaded with exercise? *
Has your child ever experienced fluttering in his/her chest, heart racing, skipped beats or chest pain? *
Has your child ever had a cardiac evaluation, an EKG, echocardiogram, or stress test? *
Has your child ever been told he/she has a heart condition? *
Does your child have any relative that has been diagnosed with a heart condition? *
Does your child have any current bone, muscle or joint pain? *
Does your child have any rashes, open wounds, cuts or sores on his/her skin? *
Does your child have only one functioning kidney or one testicle, if male? *
Does your child worry about his/her weight? *
Does your child have any stomach or digestive problems? *
Has your child ever had a broken bone? *
Has your child ever had surgery? *
Does your child require any special accommodations for participation in athletics? *
Please explain any question you answered YES to. Please provide dates.
If you have questions about this form, or would like to provide additional information, please contact Mrs. Ortiz RN School Nurse: Jortiz@fortannschool.org
Parent/Guardian Signature: *
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