Online HHQ Update | Maple Shade High School

Health History Update

To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose physical examination was completed more than 60 days prior to the first day of the official practice shall provide a health history update questionnaire completed and signed by the student's parent or guardian.

Please answer yes or no to each of the questions below. If you answer yes, please explain in detail as to why you answered yes. Since the last pre-participation physical examination, has your son/daughter:

Student First Name: *

Student Last Name: *

Phone: *

E-mail: *

Age: *

Grade: *

Date of Last Physical Examination: *

Month

Day

Year

Sport: *

Since the last physical examination, have you been medically advised not to participate in a sport?: *

Since the last physical examination, have you sustained a concussion, been unconscious or lost memory from a blow to the head?: *

Since the last physical examination, have you broken a bone or sprained/strained/dislocated any muscle or joints?: *

Since the last physical examination, Have you fainted or "blacked out?": *

Since the last physical examination, Have you experienced chest pains, shortness of breath or "racing heart?": *

Since the last physical examination, has there been a recent history of fatigue and unusual tiredness?: *

Since the last physical examination, have you been hospitalized or had to go to the emergency room?: *

Since the last physical examination, has there been a sudden death in the family or has any member of the family under age 50 had a heart attack or "heart trouble?": *

Since the last physical examination, have you started or stopped taking any over-the-counter or prescribed medications?: *

Have you been diagnosed with Coronavirus (COVID-19)? IF so, what was the date?: *

If diagnosed with Coronavirus (COVID-19), were you symptomatic?:

If diagnosed with Coronavirus (COVID-19), were you hospitalized?:

Has any member of the household been diagnosed with Coronavirus (COVID-19)? if so, was the person quarantined?: *

District Student ID Number: *

Date signed: *

Month

Day

Year

Name of Person Completing Form:

I hereby agree that all information above has been entered truthfully. Any answers marked as yes, have been explained.

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