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Sports medicine / Orthopedic surgery / Athletic training / Concussion / Post-concussion syndrome / Concussion grading systems / Medicine / Health / Neurotrauma


Ohio High School Athletic Association PREPARTICIPATION PHYSICAL EVALUATIONPage 1 of 6 HISTORY FORM – Please be advised that this paper form is no longer the OHSAA standard. (Note: This form is to be filled o
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Document Date: 2015-05-06 11:22:34

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City

Columbus / /

Facility

American College of Sports Medicine / /

IndustryTerm

transportation / energy drinks / nutritional-including energy drinks/ protein supplements / assistive device / family insurance / family insurance company name / unexplained car accident / qualified healthcare professional / interscholastic sports programs / intense non‐contact sports specific drills / /

MedicalCondition

myopia / loss of consciousness / Post-Concussion Syndrome / Allergies / another injury / tinea corporis Neurologic MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck walk / hypertrophic cardiomyopathy / headaches / catecholaminergic polymorphic ventricular tachycardia / HIV / MRSA (staph) skin infection / heart infection / headache / brain injury / arachnodactyly / Nausea / unexplained fainting / cold sores / herpes / frequent seizures / pectus excavatum / juvenile arthritis / short QT syndrome / numbness / injury / specific allergy / eye injury / muscle cramps / sudden infant death syndrome / illness / autonomic dysreflexia / tiredness / hearing loss / unexplained seizure / muscle spasticity / bladder Numbness / head injury / asthma / long QT syndrome / paralysis / taken asthma / Brugada syndrome / unexplained seizures / joint injury / disease / pressure sores / athlete’s injury / Easy bleeding Enlarged spleen Hepatitis Osteopenia / hypothermia / seizure disorder / dwarfism / hernia / Hepatitis B. Although serious injuries / High cholesterol / pain / vomiting / Second Impact Syndrome / Marfan syndrome / eating disorder / epilepsy / head injuries / sickle cell trait / High blood pressure / infectious mononucleosis / dizziness / arryhthmogenic right ventricular cardiomyopathy / infectious disease / connective tissue disease / Any headache / syndrome / injuries / /

MedicalTreatment

surgery / /

Organization

American Academy of Family Physicians / Ohio Department of Health Violence and Injury Prevention Program / Sports Medicine / and American Osteopathic Academy of Sports Medicine / Ohio High School Athletic Association / American Orthopaedic Society for Sports Medicine / Ohio Department of Health Concussion Information Sheet For Interscholastic Athletics Dear Parent/Guardian and Athletes / Centers for Disease Control and Prevention / American College of Sports Medicine / Federation of State High School Associations / Ohio Department of Health Concussion Information Sheet For Interscholastic Athletics Acknowledgement of Having Received / American Academy of Pediatrics / Department of Health / Association of America www.biausa.org/ / OHSAA / /

Person

Code / /

Position

personal representative / principal and athletic administrator / A.N.P. EMERGENCY INFORMATION Personal Physician / PHYSICIAN / school counselor / student-athlete / athletic director / coach / teacher / physical education teacher / school nurse / personal physician / school administrator / administrator / ATHLETE / coach / school nurse / coach and physical education teacher / assistant / /

ProvinceOrState

Ohio / /

Technology

x-ray / Sports Medicine / MRI / /

URL

www.healthyohioprogram.org/concussion / www.cdc.gov/Concussion / ohsaa.org / www.healthyohioprogram.org/vipp/injury.aspx / www.nfhs.org / www.biausa.org / /

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