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Athletics Health History Update Form
Haverling Jr/Sr HS Medical Eligibility Certification for participation in athletics
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* Indicates required question
Email
*
Your answer
Name
*
Your answer
Grade Level
*
Choose
12th
11th
10th
9th
8th
7th
Sport
Your answer
1. Any injuries requiring medical attention since your last physical?
*
Yes
No
If you answered yes to question 1 please explain
Your answer
2. Any recent illness lasting more then 5 days?
*
Yes
No
If you answered yes to question 2 please explain
Your answer
3. Are you taking any medications or under a physicians care at this time?
*
Yes
No
If you answered yes to question 3 please explain
Your answer
4. Have you had any surgical procedures or fracture? *
*
Yes
No
If you answered yes to question 4, please explain.
Your answer
5. Have you been treated in a hospital or an emergency room since your last physical?
*
Yes
No
If you answered yes to question 5, please explain.
Your answer
6. Do you have asthma?
*
Yes
No
7. Do you have any known allergies?
*
Yes
No
If you answered yes to question 7, please explain.
Your answer
8. Have you had any chronic illness?
*
Yes
No
9. Have you ever tested positive for COVID 19?
Yes
No
Clear selection
If you answered yes to question 9 give date when you tested positive.
MM
/
DD
/
YYYY
If you answered yes to question 9 were you symptomatic and/or hospitalized?
Yes
No
Clear selection
If you answered yes to question 9 were you diagnosed with Multisystem Inflammatory Syndrome (MISC)?
Yes
No
Clear selection
10. Have you ever had a test by a health care provider for your heart (EKG, echocardiogram, stress test)?
Yes
No
Clear selection
11. Do you feel faint, dizzy or fatigued after heavy exertion?
Yes
No
Clear selection
12. Do you have chest pain, tightness or pressure during or after exercise?
Yes
No
Clear selection
13. Do you ever experience fluttering in the chest, skipped heartbeats or heart racing?
Yes
No
Clear selection
14. Have you ever been told by a health care provider that you have or had a heart or blood vessel problem?
Yes
No
Clear selection
15. Do you have a family history of known heart abnormalities or sudden death before the age of 50?
Yes
No
Clear selection
If you answered yes to question 15 please explain.
Your answer
By entering your initials below you certify that the response above are true and accurate.
Initials
*
Your answer
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