A COMPLETED PHYSICAL MUST BE ON FILE WITH THE ATHLETIC TRAINER BEFORE A STUDENT ATHLETE CAN PARTICIPATE IN ANY ATHLETIC ACTIVITY

Transcription

1 Paid: HUMBLE INDEPENDENT SCHOOL DISTRICT UIL ATHLETIC PARTICIPATION FORM *Please use Blue/Black ink and Print legibly* Fill in all BLANKS If items do not apply please write N/A RECEIPT # Receipt by: A COMPLETED PHYSICAL MUST BE ON FILE WITH THE ATHLETIC TRAINER BEFORE A STUDENT ATHLETE CAN PARTICIPATE IN ANY ATHLETIC ACTIVITY All Physicals must be the ORIGINAL (no copies fax, etc.) and the CORRECT SCHOOL YEAR. Physicals for the school year must be performed after April 1, 2015 to be valid. It is the athlete s responsibility to update new information as soon as it becomes available. (New address, phone number, etc ) Student ID #: Gender: Male / Female Date of Birth: Age: Grade ( ): Last Name: First Name: M.I: Home Phone: Cell Number: Address: City/Zip: Circle the school that you will be attending in : AHS HHS KHS KPHS SCHS AMS CMS HMS KMS RMS RSMS TMS WCMS SPORT (s) Parent/Guardian 1: Relationship: Phone #: Parent/Guardian 2: Relationship: Phone #: Address: Address: LIVES WITH: YES NO LIVES WITH: YES NO EMERGENCY CONTACT: Please list the emergency contact other than name above IN CASE a parent/guardian CANNOT be reached: Name: Relationship: Cell Number: Home Phone: Work Number: Other Phone: HEALTH INSURANCE INFORMATION: Please provide ALL Insurance Information for your student-athlete. Insurance Company Name: Address: City: State: Zip: Phone: ID #: Policy #: Group ID #: Network #: Family Physician: Office Phone: CHECK HERE IF THIS ATHLETE IS NOT COVERED UNDER ANY FORM OF HEALTH INSURANCE AT THIS TIME. Humble Independent School District offers a Student Accident Insurance Policy for all Humble ISD athletes. This insurance policy is NOT a replacement of any other insurance policy. This insurance policy is available to all student athletes. It is offered to assist in the diagnosis and/or treatment of any athletic related injuries. Injuries that are not school related athletic activities will not be covered by this insurance. This insurance is secondary to the insurance policy that the parent/or guardian has on the student athlete. This insurance is not designed to cover all cost, but to aide in the total cost of medical treatment. It is the responsibility of the parent/guardian to request a claim form within 90 days of the injury, and to submit claim form to the insurance company. Further information about this supplemental insurance can be found through the athletic trainer s office at the student athlete s campus. PLEASE IDENTIFY ANY MEDICAL CONDITIONS THAT THE ATHLETE HAS BEEN DIAGNOSED WITH: ASTHMA HEART CONDITION EPILEPSY SICKLE CELL DIABETES Allergy to: Please explain any issues: MEDICATIONS: Please list ANY prescribed medications that the student-athlete is currently taking. (Student Athletes carrying Inhalers must have a Student Asthma Action Plan on file with the Campus Nurse and/or Athletic Trainer.) Asthma Inhaler Medication Reason for Medication Medication Medication Reason for Medication Reason for Medication

2 PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY REVISED Student's Name: (print) This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event. YES NO YES NO 1. Have you had a medical illness or injury since your last check up or sports physical? 2. Have you been hospitalized overnight in the past year? a. Have you ever had surgery? 3. Have you ever had prior testing for the heart ordered by a physician? a.have you ever passed out during or after exercise? b.have you ever had chest pains during or after exercise? c.do you get tired more quickly than your friends do during exercise? d.have you ever had racing heart or skipped heartbeats? e.have you have or have had high blood pressure or high cholesterol? f.have you ever been told you have a heart murmur? g.has any family member or relative died of heart problems or of sudden unexpected death before age 50? h.has any family member been diagnosed with enlarged heart hypertrophic cardiomyopathy, long QT syndrome, Marfan s syndrome, or abnormal heart rhythm? i.have you had a severe viral infection (for example myocarditis or mononucleosis) within the last month? j.has a physician ever denied or restricted your participation in sports for any heart related problems? 4. Have you ever had a head injury or concussion? a.have you ever been knocked out, become unconscious, or lost your memory? If YES, how many times? When was the last concussion? How severe was each one? (Explain) b.have you ever had a seizure? c.do you have frequent or severe headaches? d.have you ever had numbness or tingling in your arms, hands, legs, or feet? e.have you ever had a stinger, burner, or pinched nerve? 6. Are you under a doctor s care? 7. Are you currently taking any prescription or nonprescription (over-the-counter) medication or pills or using an inhaler? 8. Do you have any allergies? (ex: to pollen, medicine, food, or insects) 9. Have you ever become dizzy during or after exercise? 10. Do you have any current skin problems? (itching, rashes, acne, warts, fungus, blisters) 11. Have you ever become ill from exercising in the heat? 12. Have you ever had any problems with your eyes or vision? 13. Have you ever gotten unexpectedly short of breath with exercise? Do you have asthma? If YES, is an inhaler required by your physician. (Must have Inhaler Action Plan on file.) Do you have seasonal allergies that require medical treatment? 14. Do you use any special protective or corrective equipment of devices that aren t usually used for your sport or position? 15. Have you ever had a sprain, strain, or swelling after injury? Have you broken or fractured any bones or dislocated any joints? Have you had any problems with pain or swelling in muscles, tendons, bones, joints? If yes, check appropriate box and explain below: o Head o Elbow o Hip o Neck o Forearm o Thigh o Back o Wrist o Knee o Chest o Hand o Shin/Calf o Shoulder o Finger o Ankle o Foot o Upper Arm 16. Do you want to weigh more or less than you do now? 17. Do you feel stressed out? 18. Have you ever been diagnosed with or treated for sickle cell trait or sickle cell disease? 19. Have you ever been diagnosed with diabetes? If YES Type I or Type II Females Only: 20. When was your first menstrual period? When was your most recent menstrual period? How much time do you usually have from the start of one period to the start of another? How many periods have you had in the last year? What the longest time between periods in the last year? 5. Are you missing any paired organs? It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any responsibility in case an accident occurs. If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student. If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL. An individual answering in the affirmative to any question relating to a possible cardiovascular health issue (question three above), as identified on the form, should be restricted from further participation until the individual is examined and cleared by a physician, physician assistant, chiropractor, or nurse. **EXPLAIN YES ANSWERS IN THE BOX BELOW (attach another sheet if necessary): If the student is adopted or living with foster parents please communicate with the athletic trainers letting them know of any known or unknown family medical history. I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL Parent Signature: Student Signature: Date: For School Use Only: This Medical History Form was reviewed by: Printed Name Date Signature

3 PREPARTICIPATION PHYSICAL EVALUATION -- PHYSICAL EXAMINATION Student's Name Sex Age Date of Birth Height Weight Pulse BP / ( /, / ) brachial blood pressure while sitting Vision: R 20/ L 20/ Corrected: o Y o N Pupils: o Equal o Unequal As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific questions on the student's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual physical exam. Medical Normal Abnormal Initials* Appearance Eyes/Ears Nose/Throat Lymph Nodes Heart- Auscultation Supine Heart - Auscultation Standing Heart - Lower Extremity Pulses Lungs Abdomen Genitalia (males only) Skin Marfan s Stigmata (arachnodactyly, pectus excauatum,joint hypermobility, scoliosis) Musculoskeletal Normal Abnormal Initials Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Knee Leg Ankle Foot *station-based examination MUST INCLUDE PHYSICIAN Clearance: STAMP TO BE VALID Cleared Cleared after completing evaluation/rehabilitation for: Not Cleared for: Reason: Recommendations: NOTE OF CLEARANCE MUST BE ON LETTERHEAD OF CLEARING PHYSICIAN The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner will not be accepted. Date of Examination: Address: Phone Number: Physician s Signature: Name: (print/type): Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches. INJURY INFORMATION: If the athlete is referred to a physician, or chooses to visit a physician on their own, documentation must be provided to the proper people. - High School: Athletic trainers - Middle School: the Head Coach of the sport you are participating in. The documentation is to include the following: - Diagnosis - Status Not only what you can t do, but also what you can do. - Treatment Options - Next appointment date. This documentation is necessary to ensure that the athlete is medically able and cleared to participate. The guidelines outlined in the documentation will be the ones followed until another notice is received from the athletes physician. If a COACH or ATHLETIC TRAINER discovers that an athlete was examined by a physician without providing documentation, they will not be allowed to participate or be provided further treatment or rehabilitation until the proper documentation is received.

4 Definition of Concussion - means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) include temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms or altered sleep patterns; and (B) involve loss of consciousness. Prevention Teach and practice safe play & proper technique. Follow the rules of play. Make sure the required protective equipment is worn for all practices and games. Protective equipment must fit properly and be inspected on a regular basis. Signs and Symptoms of Concussion The signs and symptoms of concussion may include but are not limited to: Head ache, appears to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vision, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion. Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT). The COT shall include at least one physician and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsychologist or a physician s assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific evidence. Treatment of Concussion - The student-athlete/cheerleader shall be removed from practice or participation immediately if suspected to have sustained a concussion. Every student-athlete/cheerleader suspected of sustaining a concussion shall be seen by a physician before they may return to athletic or cheerleading participation. The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of computer, and bright lights. When all signs and symptoms of concussion have cleared and the student has received written clearance from a physician, the student-athlete/cheerleader may begin their district s Return to Play protocol as determined by the Concussion Oversight Team. Return to Play - According to the Texas Education Code, Section : A student removed from an interscholastic athletics practice or competition (including per UIL rule, cheerleading) under Section may not be permitted to practice or participate again following the force or impact believed to have caused the concussion until: (1) the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student s parent or guardian or another person with legal authority to make medical decisions for the student; (2) the student has successfully completed each requirement of the return-to-play protocol established under Section necessary for the student to return to play; (3) the treating physician has provided a written statement indicating that, in the physician s professional judgment, it is safe for the student to return to play; and (4) the student and the student s parent or guardian or another person with legal authority to make medical decisions for the student: (A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play; (B) have provided the treating physician s written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and (C) have signed a consent form indicating that the person signing: (i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-to-play protocol; (ii) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol; (iii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No ), of the treating physician s written statement under Subdivision (3) and, if any, the return-to-play recommendations of the treating physician; and (iv) understands the immunity provisions under Section Parent Name Parent Signature Date Student Name Student Signature Date

5 What is Sudden Cardiac Arrest? Name: Occurs suddenly and often without warning. An electrical malfunction (short circuit) causes the bottom chambers of the heart (ventricles) to beat dangerously fast (ventricular tachycardia or fibrillation) and disrupts the pumping ability of the heart. The heart cannot pump blood to the brain, lungs and other organs of the body. The person loses consciousness (passes out) and has no pulse. Death occurs within minutes if not treated immediately. What causes Sudden Cardiac Arrest? Conditions present at birth Inherited (passed on from parents/relatives) conditions of the heart muscle: Hypertrophic Cardiomyopathy- (hypertrophy) of the left ventricle; the most common cause of sudden cardiac arrest in athletes in the U.S. Arrhythmogenic Right Ventricular Cardiomyopathy- replacement of part of the right ventricle by fat and scar; the most common cause of sudden cardiac arrest in Italy. Marfan Syndrome- a disorder of the structure of blood vessels that makes them prone to rupture; often associated with very long arms and usually flexible joints Inherited conditions of the electrical system: Long QT Syndrome abnormality in the ion channels (electrical system) of the heart. Catecholaminergic Polymorphic Ventricular Tachycardia and Brugada Syndrome other types of electrical abnormalities that are rare but run in families. NonInherited (not passed on from the family, but still present at birth) conditions: Coronary Artery Abnormalities- abnormality of the blood vessels that supply blood to the heart muscle. The second most common cause of sudden cardiac arrest in athletes in the U.S. Aortic Valve Abnormalities- failure of the aortic valve (the valve between the heart and aorta) to develop properly; usually causes a loud heart murmur. Non- compaction Cardiomyopathy a condition where the heart muscle does not develop normally. Wolff-Parkinson-White Syndrome- an extra conducting fiber is present in the heart s electrical system and can increase the risk of arrhythmias. Conditions not present at birth but acquired later in life: Commotio Cordis concussion of the heart that can occur from being hit in the chest by a ball, puck, or fist. Myocarditis infection/inflammation of the heart, usually caused by a virus. Recreational/Performance- Enhancing drug use. Idiopathic: Sometimes the underlying cause of the Sudden Cardiac Arrest is unknown, even after autopsy. What are the symptoms/warning signs of Sudden Cardiac Arrest? Fainting/blackouts (especially during exercise) Dizziness Unusual fatigue/weakness Chest pain Shortness of breath Nausea/vomiting Palpitations (heart is beating unusually fast or skipping beats) Family history of sudden cardiac arrest at age < 50 ANY of these symptoms/warning signs that occur while exercising may necessitate further evaluation from your physician before returning to practice or a game. What is the treatment for Sudden Cardiac Arrest? Time is critical and an immediate response is vital. CALL 911 Begin CPR Use an Automated External Defibrillator (AED) What are ways to screen for Sudden Cardiac Arrest? The American Heart Association recommends a pre-participation history and physical including 14 important cardiac elements. The UIL Pre-Participation Physical Evaluation- Medical History form includes ALL 14 of these important cardiac elements and is mandatory annually. Additional screening using an electrocardiogram and/or an echocardiogram is readily available to all athletes, but is not mandatory. Where can one find information on additional screening? Check the Health & Safety page of the UIL website ( or do an internet search for Sudden Cardiac Arrest. Parent Name Parent Signature Date Student Name Student Signature Date

6 HUMBLE ISD NEUROCOGNITIVE TESTING Humble ISD will be utilizing ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) for pre-season baseline testing in all contact sports and post-injury testing if seen by an ImPACT trained doctor as a tool in the concussion management protocol. ImPACT is a noninvasive test that is essentially a preseason physical for the brain. ImPACT tests memory, reaction time, speed and concentration. ImPACT provides us the best available information for managing concussions and preventing potential brain damage that can occur with multiple concussions. The ImPACT test will be administered free of charge and records will be held at the students home high school. Information gathered from the ImPACT test will be used by the physician to decide treatment time, in school modifications as well as other necessary modifications to allow the student to heal faster. Please list any concussions over the last 2 years with date and number of days missed (if known) For Athletic Trainer Use ONLY: Date of Baseline: University Interscholastic League Parent and Student Agreement/Acknowledgement Form Anabolic Steroid Use and Random Steroid Testing Texas state law prohibits possessing, dispensing, delivering or administering a steroid in a manner not allowed by state law. Texas state law also provides that body building, muscle enhancement or the increase in muscle bulk or strength through the use of a steroid by a person who is in good health is not a valid medical purpose. Texas state law requires that only a licensed practitioner with prescriptive authority may prescribe a steroid for a person. Any violation of state law concerning steroids is a criminal offense punishable by confinement in jail or imprisonment in the Texas Department of Criminal Justice. STUDENT ACKNOWLEDGEMENT AND AGREEMENT As a prerequisite to participation in UIL athletic activities, I agree that I will not use anabolic steroids as defined in the UIL Anabolic Steroid Testing Program Protocol. I have read this form and understand that I may be asked to submit to testing for the presence of anabolic steroids in my body, and I do hereby agree to submit to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject me to penalties as determined by UIL. Student Name (Print): Signature: Date: Grade PARENT/GUARDIAN CERTIFICATION AND ACKNOWLEDGEMENT As a prerequisite to participation by my student in UIL athletic activities, I certify and acknowledge that I have read this form and understand that my student must refrain from anabolic steroid use and may be asked to submit to testing for the presence of anabolic steroids in his/her body. I do hereby agree to submit my child to such testing and analysis by a certified laboratory. I further understand and agree that the results of the steroid testing may be provided to certain individuals in my student s high school as specified in the UIL Anabolic Steroid Testing Program Protocol which is available on the UIL website at I understand and agree that the results of steroid testing will be held confidential to the extent required by law. I understand that failure to provide accurate and truthful information could subject my student to penalties as determined by UIL. Name (Print): Signature: Date: Relationship to student: School Year (to be completed annually)

7 **INCOMMING FRESHMAN ONLY** ELECTROCARDIOGRAM SCREEN (ECG) CONSENT FORM AND RELEASE OF LIABILITY An ECG screen can help identify young athletes who are at risk for sudden cardiac death as noted in the previous page on Sudden Cardiac Death. An ECG screen may assist in diagnosing several different heart conditions that may contribute to sudden cardiac death. Humble ISD is now requiring all incoming freshmen involved in athletics to receive a free ECG (ELECTROCARDIOGRAM) as part of their on campus physical day only. By signing below, I am declining an ECG screen provided by the Humble Independent School District for my child. By electing to receive an ECG screen, I acknowledge the limitations of an ECG screen and that sudden cardiac death is still possible, despite this screening. I further acknowledge that students with an abnormal ECG screen will be required to perform further testing and /or a medical consultation prior to being released to resume participation for HISD activities. I hereby release and forever discharge, and waive, any and all claims against the Humble Independent School District, its employees, trustees, consultants and contractors that relate to the student s election regarding and/or participation in the ECG screening project, and authorize medical personnel to review the ECG results, and interpret and use the same for diagnostic and aggregated statistical purposes in addition to other medical documentation on file in with the school district, and in accordance with the Family Educational Privacy Rights Act and the Health Insurance Portability and Accountability Act of I DECLINE participation in the ECG screen on behalf or that of my minor child. Parent/Guardian Name Printed Parent/Guardian Signature Date Information ECG Date: Preformed by: Result: **HIGH SCHOOL STUDENTS INCLUDING THOSE GOING IN TO THE 9 TH GRADE** Return your completed form to your campus Athletic Training Room. ** DO NOT GIVE ANY FORMS TO COACH OR NURSE** After turning your physical into the ATHLETIC TRAINER keep the white receipt and take the yellow receipt to the HEAD COACH. Keep the white receipt for your records and any other sports you may want to participate in. You must have a YELLOW receipt to give your HEAD COACH before you will be allowed to participate in ANY UIL in or out of season sport(s). **DO NOT LOSE YOUR WHITE RECEIPT. THIS IS PROOF YOU TURNED IN A PHYSICAL FORM** ** MIDDLE SCHOOL STUDENTS ONLY** Middle School Students (going to the 7 th and 8 th grades only) return all completed forms to the HEAD COACH. After turning your physical to the HEAD COACH they will give you a receipt. BE SURE TO KEEP A RECEIPT FOR YOUR RECORDS If you have any questions about this form, including SUMMER turn in locations and times Please call the Humble ISD Athletic Office at or your campus athletic training room. Atascocita HS Humble HS Kingwood HS Kingwood Park HS Summer Creek HS