This sample Health History form is designed to be completed and signed by Parents/Guardians and athletes and returned to school personnel before students may participate in sports.

Here is a sample section of the document and health history form (click the Download link to access the entire document and form):

Dear Parents and Athletes,

Interscholastic sports medical examinations are given once a year and are valid for 12 months.  Regulations require us to update each athlete's medical history prior to the start of each new sports season, if it has been more than 30 days since he/she was examined by the school physician.  This is done to be sure that there are no health changes, which would interfere with his/her continued participation in interscholastic sports.

Please Provide Us With the Following Information

1. Any injuries requiring medical attention?
2. Any illness lasting more than five (5) days?
3. Taking any medicine or under physician’s care at the time? 
4. Any feeling of faintness, dizziness or fatigue after heavy exertion?
5. Wear glasses or contact lenses?
6. A surgical operation or fracture?
7. Treated in a hospital or emergency room?
8. Any reason why this person cannot participate in any sport?
9. Any known allergies?
10.  Any Chronic diseases?

Click the Download link to access the entire sample Health History form.