| Document Date: 2014-01-09 08:47:33
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Company BP / / Event Person Communication and Meetings / / IndustryTerm car accident / / MedicalCondition allergies / Sprengel’s deformity / exercise-induced asthma / hypertension / heart infection / seizures / fainting / uncontrolled seizures / GENITALIA (MALES) HERNIA / uncontrolled diabetes / acute infections / diabetes / unexplained heart attacks / seizure / pulmonary insufficiency / pain / injury / organic heart disease / sickle cell disease / eating disorder / severe muscle cramps / extreme fatigue / high blood pressure / sickle cell trait / heat stroke / sudden infant death syndrome / cough / unexplained seizure / exercise asthma / chronic musculoskeletal condition / chronic medical illnesses / head injury / asthma / heat injury / / MedicalTreatment surgery / / Organization PA NP / North Carolina High School Athletic Association Sports Medicine Advisory Committee / NCHSAA Board of Directors / / Position regular physician / Athlete / Physician / Licensed Physician / Nurse / parent/legal custodian / Physician Assistant / legal custodian / / Technology Sports Medicine / /
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NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient’s Name: ____________________________________________________ Age: ______