SHENENDEHOWA                              Sports Recertification
      CENTRAL SCHOOLS                                                    Interval Health History*       
                                                                                                 Fall/Winter/Spring

Student____________________________________________________________Age_____________
Grade ________   Birthdate ______________  Sport _____________  School Building _______________
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To Parent or Guardian: Please complete this form in addition to the Health History if the physical was done more than 30 days before the sport begins.
If your child was examined and approved for participation in interscholastic athletics this school year, please complete the following:
NOTE:  “Yes” to any of these questions does not mean automatic disqualification from the athletic activity.  However, it will require a review and approval by the school physician before the student can report to practice or tryouts.

History since last physical:                                                                                              YES       NO
1. Has your child experienced any type of head injury or concussion requiring medical attention?    
2. Has your child received any injury requiring medical attention?    
3. Has your child had any surgical operations, joint injuries, or fractured bones?    
4. Has your child been treated in a hospital or emergency room?    
5. Has your child been diagnosed with any condition requiring medical attention?    
6. Has your child experienced swelling or pain requiring medical attention?    
7. Has your child missed any practices under/or games due to illness or injury?    
8. Has your child been absent from school for five (5) or more consecutive days (or an equivalent period during the summer) due to an accident or illness requiring medical care?    
9. Has injury or illness prevented your child from exercise or other athletic activities?    
10. Is your child currently taking any prescription or nonprescription (over the counter) medication or pills or using an inhaler?    
11. Will your child carry any medication or pills or inhaler in school or at sports activities?    
12. Has your child experienced any feelings of faintness, dizziness or fatigue after exercise or exertion?    
13. Has there been any change in vision, such as wearing glasses or contact lens?    
14. Has our child developed any allergies?    
15. Has your child developed asthma?    
16. Females Only:  When was your last menstrual period?______________________________    
Describe the condition or situation that caused any questions listed above to be answered “YES”:
________________________________________________________________________________________
________________________________________________________________________________________
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PARENT PERMISSION
 I, the undersigned, clearly understand these questions are asked in order to decide if my child can safely participate on the athletic team named above.  The answers are correct as of this date and he/she has my permission to participate.
 Parent Signature__________________________Date____________
Student Signature_________________________Date____________
Work phone__________________  Home phone _______________________ Cell phone__________________
*Please complete this form in addition to the Health History if the physical was done more than 30 days before the sport begins.
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 Part B - To be completed by the school nurse:

Date of last health appraisal____________________ Absences _________________P.E. excuses ______________
School Nurse_________________________________________ Date___________________________________
HPE7 (revised March 2006)