Health History Fall 2023
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This Health History is to be completed by Parent/Guardian. Please provide details to any YES answer in the bottom section. Must be completed within 30 days of the start of the season.
Any medications to be taken at practice and/or athletic events will require the proper paperwork, contact school with questions
School student attends: *
Student Last Name *
Student First Name *
Student DOB *
MM
/
DD
/
YYYY
Student Age (as of first day of season) *
Grade *
Sport *
Level *
Coaches' email (New coach's emails Girls Soccer rchunco@newfanecentralschools.org,  Varsity alevinton@newfanecentralschools.org, JV  Boys Soccer JV  alevinton@newfanecentralschools.org *
Does your child have any limitations? *
Date of last health exam *
MM
/
DD
/
YYYY
Date form completed (today's date) *
MM
/
DD
/
YYYY
General Health Concerns
Has/does your child:
Has/does your child: *
Yes
No
Ever been restricted by a doctor, physician assistant, or nurse practitioner from sports participation for any reason?
Ever had surgery?
Ever spent the night in a hospital?
Been diagnosed with Mononucleosis within the last month?
Have only one functioning kidney?
Have a bleeding disorder?
Have any problems with his/her hearing or wears hearing aid(s)
Have any problems with his/her vision or has vision in only one eye?
Wear glasses or contacts?
Does your child have an ongoing medical condition? *
Required
Allergies
Does your child have a life threatening allergy? Check all that apply: *
Required
Does your child carry an epinephrine auto-injector? *
Breathing (Respiratory) Health
Has/does your child: *
Yes
No
Ever complained of getting more tired or short of breath than his/her friends during exercise?
Wheeze or cough frequently during or after exercise?
Ever been told by their health care provider they have asthma?
Use or carry an inhaler or nebulizer?
Concussion/Head Injury History
Has/Does your child: *
Yes
No
Ever had a hit to the head that caused headache, dizziness, nausea, confusion, or been told he/she has a concussion?
Have you ever had a head injury or concussion?
Ever had headaches with exercise?
Ever had any unexplained seizures?
Currently receive treatment for a seizure disorder or epilepsy?
Devices/Accommodations
Has/Does your child: *
Yes
No
Use a brace, orthotic, or other device?
Have any special devices or prostheses (insulin pump, glucose sensor, ostomy bag, etc.)? If yes, there may be a need for another required form
Wear protective eyewear, such as goggles or a face shield?
Family History
Has/Does your child: *
Yes
No
Have any relative who's been diagnosed with a heart condition, such as a murmur, developed hypertrophic cardiomyopathy, Marfan Syndrome, Brugada Syndrom, right ventricular cardiomyopathy, long QT or short QT syndrome, or catecholaminergic polymorphic ventricular tachycardia?
Females only
Has/does your child:
Yes
No
Begun having her period?
Have regular periods
Clear selection
Age periods began:
Date of last menstrual period:
MM
/
DD
/
YYYY
Males only
Has/does your child:
Yes
No
Have only one testicle?
Have groin pain or a bulge or hernia in the groin?
Clear selection
Heart Health
Has/Does your child: *
Yes
No
Ever passed out during or after exercise?
Ever complained of light headedness or dissiness during or after exercise?
Ever complained of chest pain, tightness or pressure during or after exercise?
Ever complained of fluttering in their chest, skipped beats, or their heart racing, or does he/she have a pacemaker?
Ever had a test by their medical provider for his/her heart (e.g. EKG, echocardiogram stress test)?
Has your child ever been told they have a heart condition or a problem by a physician? *
Required
Injury History
Has/does your child: *
Yes
No
Ever been diagnosed with a stress fracture?
Ever been unable to move his/her arms and legs, or had tingling, numbness, or weakness after being hit or falling?
Ever had an injury, pain, or swelling of joint that caused him/her to miss practice or a game?
Have a bone, muscle, or joint injury that bothers him/her?
Have joints become painful, swollen, warm, or red with use?
Skin Health
Has/Does your child: *
Yes
No
Currently have any rashes, pressure sores, or other skin problems?
Have had a herpes or MRSA skin infection?
Stomach Health
Has/Does your child: *
Yes
No
Ever become ill while exercising in hot weather?
Have a special diet or have to avoid certain foods?
Have to worry about his/her weight?
Have stomach issues?
Had an eating disorder
Covid-19 Information
Has your child ever tested positive for COVID-19? *
Was your child symptomatic? *
Did your child see a healthcare provider (HCP) for his/her/their COVID-19 symptoms? *
Did your child have any cardiac symptoms? *
Required
Was your child hospitalized? *
If yes, was your child diagnosed with Multisystem Inflammatory syndrome (MISC)? *
If yes, is your child under an HCP's care for this? *
Explanation
Please fully explain any question you answered yes to in the space below. Provide dates if known.
Family Heart and Health History: Please check all boxes that apply if a a relative has/ had any of the following. If you have no family history of heart ailment, please check the box "no family history of heart ailments. *
Required
If you answered YES to any questions give details.
Parent email address *
Digital Signature (Full name of person completing form). By signing, you are indicating all information provided is accurate to the best of your knowledge. *
Relation to athlete: *
Submit
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