Recommended NYSED Interval Health History for Athletics
Health history to be completed by Parent/Guardian, please provide details to any "YES" answers on the bottom. Any medications to be taken at practice and/or athletic event will require the proper paperwork, contact the school with questions.
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Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
School Name *
Student Age *
Grade (Check one) *
Level (Check one) *
Sport *
Limitations *
Date of last health exam: *
MM
/
DD
/
YYYY
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