A. A medical examination conducted to determine the fitness of a pupil grades six through twelve for participation in a school-sponsored interscholastic or intramural athletic team or squad shall include, as a minimum, the following:

1. Health History Questionnaire

A health history questionnaire must be completed as part of the required medical examination.

The history questionnaire shall be completed and signed by the parent(s) or legal guardian(s) of the pupil, to determine whether the pupil:

a. Has been medically advised not to participate in any sport, and the reason for such advice,

b. Is under physician’s care and the reasons for such care,

c. Has experienced loss of consciousness after an injury,

d. Has experienced a fracture or dislocation,

e. Has undergone any surgery,

f. Takes any medication on a regular basis, the names of such medication, and the reasons for such medication,

g. Has allergies including, but not limited to: hives, asthma, and or reactions to bee stings,

h. Has experienced frequent chest pains or palpitations,

i. Has a recent history of fatigue and undue tiredness,

j. Has a history of fainting with exercise,

k. Has a history of a family member experiencing sudden death who died suddenly, and

l. Has a history of any past health events required to be reported to the examining physician, advanced practice nurse, or physician’s assistant.

2. Report of Health Findings of the Medical Examination

The report of health findings of the medical examination for pupils in grades six through twelve participating in a school-sponsored interscholastic or intramural athletic team or squad shall be documented on the Preparticipation Physical Examination Form approved by the Commissioner of Education to determine whether the pupil had or currently has any of the following conditions since their last physical:

a. Injuries

b. Chronic or ongoing illness;

c. Prescribed medication;

d. Allergies;

e. Head-related injuries;

f. Hearth related conditions;

g. Eye, ear, nose, mouth, or throat conditions;

h. Neuromuscular/orthopedic condition; and

i. General or exercise related conditions.

3. Medical Report Determination

The medical report shall include a determination concerning the pupil’s participation from the examining physician, advanced practice nurse, or physician’s assistant which includes, at a minimum, the following normalities:

a. Measurement of weight, height, and blood pressure;

b. Examination of the skin to determine the presence of infection, scars of previous surgery or trauma, jaundice, and purpura;

c. Examination of the eyes to determine visual acuity, use of eyeglasses or contact lenses and examination of the sclera for the presence of jaundice;

d. Examination of the ears to determine the presence of acute or chronic infection, perforation of the eardrum, and gross hearing loss;

e. Examination of the nose to assess the presence of deformity which may affect endurance;

f. Assessment of the neck, back, and spine to determine range of motion, the presence of pain associated with such motion, and abnormal curvature of the spine;

g. Examination of chest contour;

h. Auscultation and percussion of the lungs;

i. Assessment of the heart with attention to the presence of murmurs, noting rhythm and rate;

j. Assessment of the abdomen with attention to the possible presence of hepatomegaly, splenomegaly, or abnormal masses;

k. Examination of upper and lower extremities to determine abnormal mobility or immobility, deformity, instability, muscle weakness or atrophy, surgical scars, and varicosities;

l. Examination of the testes to determine presence and descent of both testes, abnormal masses or configurations, or hernia;

m. Assessment of physiological maturation; and

n. Neurological examination to assess balance and coordination.

The medical report shall indicate whether the pupil is allowed or disallowed to participate in a program of athletic competition and must be completed and signed by the original examining physician, advanced practice nurse, or physician’s assistant. A form that is incomplete shall be returned to the pupil’s medical home for completion. A pupil that does not have a completed Athletic Preparticipation Physical Examination Form shall not be permitted to participate.

B. Health History Update

Each pupil whose medical examination was completed more than sixty days prior to the first practice session of the athletic competition shall provide a health history update of medical problems experienced since the last medical examination. The health history update, completed and signed by the pupil’s parent(s) or legal guardian(s), shall include the following information about the pupil:

1. Hospitalizations and operations,

2. Illnesses,

3. Injuries,

4. Care administered by a physician of medicine or osteopathy, advanced practice nurse, or physician’s assistant, and

5. Medications.

C. Written Notification to Parent/Legal Guardian

The school district will provide written notification to the parent(s) or legal guardian(s), signed by the school physician, stating approval of the pupil’s participation in a program of athletic competition based solely on the medical report, or the reasons for the school physician’s disapproval of the pupil’s participation.

Adopted: August 30, 2007

Revised: October 2013