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MSHSL Annual Sports Health Questionnaire
Participant Information (one form per student)
Student Name (First & Last)
*
Birth Date
*
+
Grade ('20-'21)
*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Parent/Guardian Information
Parent Name
*
Parent Email
*
Check Yes or No boxes for each question.
In the last year, has a doctor restricted your student's participation in sports for any reason without clearing you to return to sports?
*
Yes
No
In the last year, has your student passed out or nearly passed out during or after exercise?
*
Yes
No
In the last year, has your student had discomfort, pain, tightness or pressure in your chest during exercise?
*
Yes
No
In the last year, has your student's heart race or skip beats (irregular beats) during exercise?
*
Yes
No
In the last year, has your student's gotten light-headed or feel more short of breath than expectted during exercise?
*
Yes
No
In the last year, has your student's had an unexplained seizure?
*
Yes
No
In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?
*
Yes
No
In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including an unexplained drowning or an unexplained car accident)?
*
Yes
No
In the last year, has any anyone in your immediate family had instances of unexplained fainting, seizures or near drowning?
*
Yes
No
In the last year, has has anyone in your immediate family been diagnosed with hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome or catecholaminergic polymorphic ventricular tachycardia?
*
Yes
No
In the last year, has has anyone in your immediate family under age 35 had a heart problem, pacemaker or implanted defibrillator?
*
Yes
No
In the last year, has your student had a head injury or concussion that still has symptoms like continuing headaches, concentration problems or memory problems?
*
Yes
No
Additional Information
Please note below any health concerns, medications or allergies that may be important for the coaches or athletic/activities director to know.
I do not know of any existing physical or additional health reason that would preclude my student's participation in athletic activities. I certify that the answers to the above questions are true and accurate and I approve my student's participation in athletic activities.
*
Date:
*
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