2020-2021 HEALTH HISTORY UPDATE QUESTIONNAIRE

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To participate in Practices and Contests in IHSAA Recognized Sports during the 2020-21 school year on a school-sponsored team, a student who had a prior pre-participation physical examination completed and such examination was completed more than 90 days prior to the first day of official practice for the student’s sport, may, in lieu of having a 2020-21 Pre-Participation Physical Examination form completed, provide this Health History Update Questionnaire, completed and signed by the student’s parent or guardian, or by the emancipated student. Provided, should any question on this Questionnaire be answered in the affirmative (‘Yes’), then the student must have a 2020-21 Pre-Participation Physical Examination form completed.

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E-mail *

Which middle school does your child attend? *

Carmel Middle School

Clay Middle School

Creekside Middle School

What is your child's first name? *

What is your child's last name? *

What grade is your child in? *

6th Grade

7th Grade

8th Grade

Since the last pre-participation physical examination, has your son/daughter been advised not to participate in a sport? *

Yes

Since the last pre-participation physical examination, has your son/daughter been diagnosed with COVID-19? *

Yes

Since the last pre-participation physical examination, has your son/daughter sustained a concussion, been unconscious, or lost memory from a blow to the head? *

Yes

Since the last pre-participation physical examination, has your son/daughter fainted or "blacked out"? *

Yes

Since the last pre-participation physical examination, has your son/daughter experienced chest pains, shortness of breath, "racing heart", or had any heart issues? *

Yes

Since the last pre-participation physical examination, has your son/daughter had a history of unusual fatigue or unusual tiredness? *

Yes

Since the last pre-participation physical examination, has your son/daughter been hospitalized or had surgery? *

Yes

Undersigned, a parent of a student, a guardian of a student or an emancipated student, verifies the information in this Questionnaire, acknowledges that a 2020-21 pre-participation physical examination (rule 3-10) is not required for a student who had a 2019-2020 Pre-Participation Physical Examination form completed, and with such knowledge, has elected not to have the student undergo a pre-participation physical examination and has assumed all responsibility for student’s participation in Practices for and in Contests in IHSAA Recognized Sports during the 2020-21 school year without having a pre-participation physical examination. Please sign below acknowledging the above information. *

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