HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name:	Date of birth:	Grade in School: -------

Date of examination: ---------------

Sport(s): 	 	

 	__

Sex assigned at birth (F, M, or intersex):  	 	 _

How do you identify your gender? (F,M, or other):		_

List past and curr ent medical conditions . 	

Have you ever had surgery? If yes  list all past surgical procedures.

Medicines and supplements : List all current prescri ptions  over-the-coun ter medicines. and suoplements (herbal and nutritional !.

Do you have any allergies? If yes, please list all your allergies (i.e.,medicines, pollens, food, stinging insects).

	Not at all	Several days	Over half the days	Nearly every day	
Feeling nervous, anxious, or on edge	0	1	2	3	
Not being able to stop or control worrying	0	1	2	3	
Little interest or pleasure in doing things	0	1	2	3	
Feeling down, depressed, or hopeless	0	1	2	3	

Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of thefollowing problems? (Circle response.)

(A sum of   3 is considered positive on either subscale [questions 1and 2, or questions 3 and 4) for screening purposes.)

	
1. Do you have any concerns that you would like to discuss with your provider?			
2. Has a provider ever denied or restricted your participation in sports for any reason?			
3. Do you have any ongoing medical issues or recent illness?			
	
4. Have you ever passed out or nearly passed out during or after exercise?			
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?			
6. Does your heart ever race, flutter in your chest,or skip beats (Irregular beats) during exercise?			
7. Has a doctor ever told you that you have any heart problems?			
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or  echocardiography.			

---------- --- -----	- ---
HEART HEALTH QUESTIONS ABOUT YOU	i

( CONTINUED  )	Yes	No    ,

9. Do you get light-headed or feel shorter of breath than your friends during exercise?			
10. Have you ever had a seizure?			
	
11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?			
12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic  right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic  poly­ morphic ventricular tachycardia (CPVT)?			
13.  Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?			

 	
	
25. Do you worry a bout your weight?			
26. Are you trying to or has anyone recommended that you gain or lose weight?			
27 . Are you on a special diet or do you avoid certai n types of foods or food grou ps?			
28. Have you  ever had  a n eati ng disorder?			
	
30. How old were you when you had your first menstrua l  period?		
31. When was your most recent menstrual period?		
32. How ma ny periods have you had i n the past 12 months?		

BONE AND JOI NT QUESTI ONS	Y es	No    I	
14.  Have you ever had a stress fracture or an injury
to a bone, muscle, ligament, joi nt, or tendon that caused you to miss a practice or game?			
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?			
	
16. Do you cough, wheeze, or have d ifficulty breathi ng during or after exercise?			
17 . Are you missi ng a kid ney, a n eye, a testicle (males), you r spleen, or a ny other orga n?			
18. Do you have groi n or testicle pai n or a painful bulge or hernia i n the groi n a rea ?			
19. Do you have a ny recurri ng skin rashes or rashes that come and go, including  herpes  or methicilli n-resista nt Staphylococcus  aureus (MRSA)?			
20. Have you had a concussion or head i njury that ca used conf usion, a prolonged headache, or memory  problems?			
21. Have you ever had nu mbness, had ti ngling, had wea kness in your arms or legs, or been  unable to move your arms or legs after bei ng hit or falli ng?			
22. Have you ever become ill while exercising in the heat?			
23. Do you or does someone i n your fa mily have sickle cell trait or disease?			
24. Have you ever had, or do you have a ny problems with you r eyes or vision?			

Explain "Yes" answers here.

Additional Questions  as authorized by the Ohio High School Athletic Association - These questions were not a part of the revised 5th edition PPE as authored by the American Academy of Pediatrics.
1 . On average, how many days per week do you engage in moderate to strenuous exercise (makes you breathe heavily or sweat)? ----------
2.  On average, how many minutes per week do you engage in exercise at this level? -----------
I hereby state that, to the best of my knowledge, my answers to the questions on th is form are complete and correct.
Signatu re  of  athlete:---------------------------------------------­
Signature of parent or guardia n: ------------------------------------------

Date:  	 	

 	 	_ 	 	__

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa· tional purposes with acknowledgment.

ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE HISTORY

Name:, 	

 	Dateofbirth:  	 	 	 	_

1. Type of disability:	
2. Date of disability:	
3. Classification (if available):	
4. Cause of disability (birth, disease, injury, or other):	
5. List the sports you are playing:	
6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?			
7. Do you use any special brace or assistive device for sports?			
8. Do you have any rashes, pressure sores, or other skin problems?			
9. Do you have a hearing loss? Do you use a hearing aid?			
10. Do you have a visual impairment?			
11. Do you use any special devices for bowel or bladder function?			
12. Do you have burning or discomfort when urinating?			
13. Have you had autonomic dysreflexia?			
14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?			
15. Do you have muscle spasticity?			
16. Do you have frequent seizures that cannot be controlled by medication?			
Explain "Yes" answers here.

Please indicate whether you have ever had any of the following conditions:

Atlantoaxial instability			
Radiographic (x-ray) evaluation for atlantoaxial instability			
Dislocated joints (more than one)			
Easy bleeding			
Enlarged spleen			
Hepatitis			
Osteopenia or osteoporosis			
Difficulty controlling bowel			
Difficulty controlling bladder			
Numbness or tingling in arms or hands			
Numbness or tingling in legs or feet			
Weakness in arms or hands			
Weakness in legs or feet			
Recent change in coordination			
Recent change in ability to walk			
Spina bifida			
Latex allergy			
Explain "Yes" answers here.

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signatureofathlete:	_		_			_		_	_
Slgnatureofparentorguardian : ------------------------------------------ Date:    -------------------------

@ 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College af Sports Medidne, American Medical Societyfor Sports Medidne, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission Is granted to reprint for noncommercial, educational purposes with acknowledgment.	.

PHYSICAL EXAMINATION FORM
Name:  	 	

 	__ Date of Birth: _	_ Grade in School:	_

PHYSICIAN REMINDERS
Consider additional questions on more-sensitive  issues.
Do you feel stressed out or under a lot of pressure?
Do you ever feel sad, hopeless,depressed, or anxious? Do you feel safe at your home or residence?
Have you ever tried cigarettes, e-cigarettes,  chewing tobacco, snuff, or  dip?
During the past 30 days, did you use chewing tobacco, snuff, or dip? Do you drink alcohol or use any other drugs?
Have you ever taken anabolic steroids or used any other performance-enhancing supplement?
Have you ever taken any supplements to help you gain or lose weight or improve your  performance?
Do you wear a seat belt, use a helmet, and use condoms?

Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia,mitral valve prolapse [MVP], and aortic insufficiency}			
Eyes, ears, nose, and throat
Pupils equal Hearing			
Lymph nodes			
Heart'
Murmurs (auscultation standing, auscultation supine, and ± Valsalva  maneuver)			
Lungs			
Abdomen			
Skin
Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or
tinea corporis			
Neurological			
	MUSCULOSKELETAL		NORMAL		ABNORMAL FINDINGS		
Neck			
Back			
Shoulder and arm			
Elbow and forearm			
Wrist, hand, and fingers			
Hip and thigh			
Knee			
Leg and ankle			
Foot and toes			

Consider  reviewing questions on cardiovascular  symptoms  (Q4-Q13 of History Form}.

.

Functional
Double-leg squat test, single-leg squat test, and box drop or step drop test

•Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi­ nation of those .

Name of health care professional (print or type):	_ 	 	 	 Address: 	 	

 	Date: -----------
 	.Phone:	_ 	 	 	

Signature of health care professional:	_ 	 	

 	 	_ 	 	__, MD, DO,DC, NP, or  PA

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial educa­ tional purposes  with  acknowledgment.

PREPARTICIPATION PHYSICAL EVALUATION - OHIO HIGH SCHOOL ATHLETIC ASSOCIATION - 2020-21
MEDICAL ELIGIBILITY FORM
Name:  ----------------------------Date of  Birth:		Grade in School:		_

Medically eligible for all sports without restriction

Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

o Medically eligible for certain sports

Not medically eligible pending further evaluation

Not medically eligible for any sports

Recommendations: ---------------------------------------

I have examined the student named on this form and completed the prepartlcipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings is on record in my office and can be made available to the school at the request of the parents. If conditions
arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type) : -------------------- Date of Exam:__	_	_

Address:	_ 	 	 	

 	_	Phone:  	_ 	_ 	_

Signature of health care professional:_ 	 	

 	, MD, DO, DC, NP, or  PA

SHARED EMERGENCY INFORMATION

Allergies:    -------------------------------------------

Medications :   ------------------------------------------

Other  information: ----------------------------------------

Emergency  contacts: ---------------------------------------

© 2019 American Academ y of Family Physicians, American Academy of Pediatrics, Ameriam College of Sports Medicine, American M edical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa­ tional purposes  with  acknowledgment.

PREPARTICIPATION  PHYSICAL EVALUATION	2020-2021	OHSAA FORM 1of 4
THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE SCHOOL

OHSAA AUTHORIZATI ON FORM	2020-2021
I hereby authorize the release and disclosure of the personal health infonnation of	("Student"), as described below, to
 	___ ("School").

The information described below may be released to the School principal or assistant principal, athletic director, coach, athletic trainer, physical education teacher, school nurse or other member of the School's administrative staff as necessary to evaluate the Student's eligibility to participate in school sponsored activities, including but not limited to interscholastic sports programs, physical education classes or other classroom activities .
Personal health infonnation of the Student which may be released and disclosed includes records of physical examinations perfonned to detennine the Student's eligibility to participate in school sponsored activities, including but not limited to the Pre-participation Evaluation form or other similar document required by the School prior to determining eligibility of the Student to participate in classroom or other School sponsored activities; records of the evaluation, diagnosis and treatment of injuries which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions,training and competition; and other records as necessary to detennine the Student's physical fitness to participate in school sponsored activities.
The personal health infonnation described above may be released or disclosed to the School by the Student's personal physician or physicians; a physician or other health care professional retained by the School to perform physical examinations to determine the Student's eligibility to participate in certain school sponsored activities or to provide treatment to students injured while participating in such activities, whether or not such physicians or other health care professionals are paid for their services or volunteer their time to the School; or any other EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other condition incurred by the student while participating in school sponsored activities.
I understand that the School has requested this authorization to release or disclose the personal health information described above to make certain decisions about the Student's health and ability to participate in certain school sponsored and classroom activities, and that the School is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be redisclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the School is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations.
I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the Student's participation in certain school sponsored activities may be conditioned on the signing of this authorization.
I understand that Imay revoke this authorization in writing at any time, except to the extent that action has been taken by a health care provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address appears below.

Name of Principal:	 	 School Address :	  	 

This authorization will expire when the student is no longer enrolled as a student at the school.

NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID. IF THE STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS AUTHORIZATION PERSONALLY.

Student's Signature	Birth date of Student, including year

Name of Student's personal representative, if applicable

I am the Student's (check one):		Parent  ___ Legal Guardian (documentation must be provided)

Signature of Student's personal representative, if applicable	Date

A copy of this signed form has been provided to the student or his/her personal representative

PREPARTICIPATION  PHYSICAL  EVALUATION	2020-2021	OHSAA FORM 2 of 4
go20.2021 Ohio High School Athletic Association Eli gibility and Authorization Statemen

This document is to be signed by the partici pant from an OHSAA member school and by the partici pant's parent.

Ihave read, understand and acknowledge receipt of the OHSAA Student Eligi bility Guide and Checklist
https://www.ohsaa.org/Portals/O/Eli gi bility/OtherEli qi bilty Docs/Eligi bilityGuideHS.pdf  which contains a summary of the eligibility rules of the Ohio High School Athletic Association. I understand that a copy of the OHSAA Handbook is on file with the principal and athletic administrator and that Imay review it, in its entirety, if Iso choose. All OHSAA bylaws and regulations from the Handbook are also posted on the OHSAA website at ohsaa.org.
I understand that an OHSAA member school must adhere to all rules and regulations that pertain to the interscholastic athletics programs that the school sponsors, but that local rules may be more stringent than OHSAA rules.
$Iunderstand that participation in interscholastic athletics is a privilege not a right.
Student Code of Responsibility
As a student athlete, Iunderstand and accept the following responsibilities:
Iwill respect the rights and beliefs of others and will treat others with courtesy and consideration.
'1\ Iwill be fully responsible for my own actions and the consequences of my actions.
Iwill respect the property of others.
$Iwill respect and obey the rules of my school and laws of my community, state and country.
Iwill show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country.
<11\ Iunderstand that a student whose character or conduct violates the school's Athletic Code or School Code of Responsibility is not in good standing and is ineligible for a period as determined by the principal.
0Informed Consent - By s nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and
Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN OHSAA-SPONSORED SPORT WITHOUT THE STUDENT'S AND PARENT'S/GUARDIAN'S  SIGNATURE.
$.Iunderstand that in the case of Injury or illness requiring treatment by medlcal personnel and transportation to a health care facility, that a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be treated and transported via ambulance to the nearest hospital.
Iconsent to medical treatment for the student following an injury or illness suffered during practice anc:Vor a contest.
$ro enable the OHSAA to determine whether the herein named student is eligible to participate in interscholastic athletics in an OHSAA member school, I consent to the release to the OHSAA any and all portions of school record files, beginning with seventh grade, of the herein named student, specifically including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s)or guardian(s), enrollment documents, financial and scholarship records, residence address of the student, academic work completed, grades received and attendance data.
$1 consent to the OHSAA's use of the herein named student's name, likeness, and athletic-related information in reports of contests, promotional literature of the Association and other materials and releases related to interscholastic athletics.
$1 understand that if Idrop a class, take course work through College Credit Plus, Credit Flexibility or other educational options, this action could affect compliance with OHSAA academic standards and my eligibility. Iaccept full responsibility for compliance with Bylaw 4-4, Scholarship, and the passing five credit standard expressed therein.
t/Ji Iunderstand all concussions are potentially serious and may result in complications induding prolonged brain damage and death if not recognized
and managed properly. Further Iunderstand that if my student is removed from a practice or competition due to a suspected concussion, he or she will be unable to return to participation that day. After that day written authorization from a physician (M.D. or D.O.) or another health care provider working under the supervision of a physician will be required in order for the student to return to participation.
$Ihave read and signed the Ohio Department of Health's Concussion I nformation Sheet and have retained a copy for myself.
$Ihave read and signed the Ohio Department of Health's Sudden Cardia Arrest I nformation Sheet and have retained a copy for myself.
.rj,By signing this we acknowledge that we have read the above information and that we consent to the herein named student's participation.
*Must Be Signed Before Physical Examination

Student's Signature	Birth date	Grade in School	Date

Parent's or Guardian's Signature	Date

Ohio Department of Health Concussion Information Sheet
For InterscholasticAthletics
Dear Parent/Guardian and Athletes,

This information sheet is provided to assist you and your child in recognizing the signs and symptoms of a concussion. Every athlete is different and responds to a brain injury differently, so seek medical attention if you suspect your child has a concus­ sion. Once a concussion occurs, it is very important your athlete return to normal activities slowly, so he/she does not do more damage to his/her brain.

What is a Concussion?
A concussion is an injury to the brain that may be caused by a blow, bump,or jolt to the head. Concussions may also happen after a fall or hit that jars the brain. A blow elsewhere on the body can cause a concussion even if an athlete does not hit his/her head directly. Concussions can range from mild to severe, and athletes can get a concussion even if they are wearing a helmet.

Signs and Symptoms of a Concussion
Athletes do not have to be "knocked out" to have a concussion. In fact, less than 1 out of 1o concussions result in loss of
consciousness. Concussion symptoms can develop right away or up to 48 hours after the injury. Ignoring any signs or symptoms of a concussion puts your child's health at risk!

Signs Observed by Parents of Guardians
Appears dazed or stunned.
Is confused about assignment or position.
Forgets plays.
Is unsure ofgame, score or opponent.
Moves clumsily.
Answer.s questions slowly
Loses consciousness (even brieflY).
+		Shows behavior orpersonality changes (irritability, sadness, nervousness, feeling more emotional).
Can't recall events before or after hit or fall.

Symptoms Reported by Athlete
Any headache or "pressure " in head. (How badly it hurts does not matter.)
Nausea or vomiting.
Balance problems or dizziness.
Double or blurry vision.
Sensitivity to light and/or noise
Feeling sluggish hazy, foggy or groggy
Concentration or memory problems.
Confusion.
Does not 'tee/ right "
Trouble falling asleep.
Sleeping more or less than usual.

Be Honest

Seek Medical Attention Right Away
Seeking medical attention is an important first step if you suspect or are told your child has a concussion . A qualified health care professional will be able to determine how serious the concussion is and when it is safe for your child to return to sports and other daily activities.
No athlete should return to activity on the same day he/ she gets a concussion.
Athletes should NEVER return to practices/games if they still have ANY symptoms.
Parents and coaches should never pressure any athlete to return to play.
The Dangers of Returning Too Soon
Returning to play too early may cause Second Impact Syndrome (SIS) or Post-Concussion Syndrome (PCS). SIS occurs when a second blow to the head happens before an athlete has completely recovered from a concussion. This second impact causes the brain to swell, possibly resulting in brain damage, paralysis, and even death. PCS can occur after a second impact. PCS can result in permanent, long-term concussion symptoms. The risk of SIS and PCS is the reason why no athlete should be allowed to participate in any physical activity before they are cleared by a qualified healthcare professional .

Recovery
A concussion can affect school, work, and sports.  Along with coaches and teachers, the school nurse, athletic trainer, employer, and other school administrators should be aware of the athlete's injury and their roles in helping the child recover.
During the recovery time after a concussion, physical and mental rest are required. A concussion upsets the way
the brain normally works and causes it to work longer and harder to complete even simple tasks. Activities that require concentration and focus may make symptoms worse and cause the brain to heal slower . Studies show
that children's brains take several weeks to heal following a concussion.

Encourage your athlete to be honest with you, his/her coach and your health care provider about his/her symptoms . Many young athletes get caught up in the moment and/or feel
pressured to return to sports before they are ready. It is better

oh·o
Departrn.rrt of Hta1th

OHIO INJURY PREVENTION

PA R TNER SHIP

to miss one game than the entire season... or risk permanent

Injury	nti<>n

Pblll:y ..rx1Adv0c _ a c y A_   e tio n _ Group

damage!

http://www.health y.ohio.gov/vi pp/ child/returntoplay/concussion

Returning to Daily Activities
Be sure your child gets plenty of rest and enough sleep at night - no late nights.  Keep the same bedtime weekdays and weekends.
Encourage daytime naps or rest breaks when your child feels tired or worn-out.
Limit your child's activities that require a lot of thinking or concentration (including social activities,
homework, video games, texting, computer, driving, job-related activities, movies, parties).  These activities can slow the brain's recovery.
.  Limit your child's physical activity, especially those activities where another injury or blow to the head may occur.
Have your qualified health care professional check your child's symptoms at different times to help guide recovery.

Returning to Learn (School)
1.  Your athlete may need to initially return to school on a limited basis, for example for only half-days, at first. This should be done under the supervision of a qualified health care professional.
Inform teacher(s), school counselor or administrator(s) about the injury and symptoms. School personnel should be instructed to watch for:
Increased problems paying attention.
Increased problems remembering or teaming new information.
Longer time needed to complete tasks or assignments.
d. Greater irritability and decreased ability to cope with stress.
e. Symptoms worsen (headache, tiredness) when doing schoolwork.
Be sure your child takes multiple breaks during study time and watch for worsening of symptoms .
If your child is still having concussion symptoms, he/ she may need extra help with school-related activities. As the symptoms decrease during recovery, the extra help or supports can be removed gradually.

For more information, please refer to Return to Learn on the OOH website.

Resources
OCH Violence and Injury Prevention Program
hUp:IJwNN.heallhy.dlo .gov/vi;ipldWd/rel!m!cPavl

Centers for Disease Control and Prevention
hUp:l/wmv.o:lc.rm/tre?dfw/'o?Sl:sfrdex.hlml

Natia'1al Federala1 r:iSIBB HtjlSchoel Assoda6a IS
www.nfhs.org

Brain Injury Association of America
www.biausa.ornl

Returning to Play
Returning to play is specific for each person, depending on the sport. Starting 4/26/13, Ohio law requires written pennission from a health care provider before an athlete can retum toplay. Follow instructions and guidance provided by a health care professional. It is important that you, your child and your child's coach follow these instructions carefully.
Your child should NEVER return to play if he/she still has ANY symptoms. (Be sure that your child does
not have any symptoms at rest and while doing any physical activity and/or activities that require a lot of thinking or concentration).
Ohio law prohibits your child from returning to a game or practice on the same day he/she was removed.
Be sure that the athletic trainer, coach and physical education teacher are aware of your child's injury and symptoms.
Your athlete should complete a step-by-step exercise
-based progression, under the direction of a qualified healthcare professional.
A sample activity progression is listed below. Generally, each step should take no less than 24 hours so that your child's full recovery would take about one week once they have no symptoms at rest and with moderate exercise.*

Sample Activity Progression*
Step 1: Low levels of non-contact physical activity, provided NO SYMPTOMS return during or after activity. (Examples: walking, light jogging, and easy stationary biking for 20-30 minutes).

Step 2: Moderate, non-contact physical activity, provided NO SYMPTOMS return during or after activity. (Examples: moderate jogging, brief sprint running, moderate stationary biking, light calisthenics, and sport­ specific drills without contact or collisions for 30-45 minutes).

Step $: Heavy, non-contact physical activity, provided NO SYMPTOMS return during or after activity. (Examples: extensive sprint running, high intensity stationary biking, resistance exercise with machines and free weights, more intense non-contact sports specific drills, agility training andjumping drills for 45-60 minutes).

Step 4: Full contact in controlled practice or scrimmage. Step 5: Full contact in game play.
*If any symptoms occur, the athlete should drop back to the previous step and try to progress again after a 24 hour rest period.

http://www.healthy.ohio.gov/vipplchild/returntoplaylconcussion
Rev. 09.r6

Ohio Department of Health Concussion Information Sheet
For Interscholastic Athletics
I have read the Ohio Department of Health's Concussion Information Sheet and understand that I have a responsibility to report my/my child's symptoms to coaches, administrators and healthcare provider.

I also understand that I/my child must have no symptoms before return to play can occur.

Athlete	Date

Athlete Please Print Name

Parent/Guardian	Date

Ohio

Department of Health

RBv.9.16

Sudden Cardiac Arrest and Lindsay's Law
Parent/Athlete Signature Form

What is Lindsay's Law? Lindsay's Law is about Sudden Cardiac Arrest (SCA) in youth athletes. It covers all athletes 19 years or younger who practice for or compete in athletic activities. Activities may be organized by a school or youth sports organization.

Which youth athletic activities are included in Lindsay's law?
Athletics at all schools in Ohio (public and non-public]
Any athletic contest or competition sponsored by or associated with a school
All interscholastic athletics, including all practices, interschool practices and scrimmages
All youth sports organizations
All cheerleading and club sports, including noncompetitive cheerleading
I What is SCA? SCA is when the heart stops beating suddenly and unexpectedly.This cuts off blood ftow to the brain and other vital organs. People with SCA will die if not treated immediately. SCA can be caused by 1l a structural issue with the heart, OR 21 an heart electrical problem which controls the heartbeat, OR 31 a situation such as a person who is hit in the chest or a gets a heart infection.
What is a warning sign for SCA? If a family member died suddenly before age 50, or a family member has cardiomyopathy,long QT syndrome, Marfan syndrome or other rhythm problems of the heart.

What symptoms are a warning sign of SCA? A young athlete may have these things with exercise:
Chest pain/discomfort
Unexplained fainting/near fainting or dizziness
Unexplained tiredness, shortness of breath or difficulty breathing
Unusually fast or racing heart beats

What happens if an athlete experiences syncope or fainting before, during or after a practice, scrimmage, or competitive play? The coach MUST remove the youth athlete from activity immediately. The youth athlete MUST be seen and cleared by a health care provider before returning to activity. This written clearance must be shared with a school or sports official.

What happens if an athlete experiences any other warning signs of SCA? The youth athlete should be seen by a health care professional.

Who can evaluate and clear youth athletes? A physician (MD or DO), a certified nurse practitioner, a clinical nurse specialist, certified nurse midwife. For school athletes, a physician's assistant or licensed athletic trainer may also clear a student. That person may refer the youth to another health care provider for further evaluation.

What is needed for the youth athlete to return to the activity? There must be clearance from the health care provider in writing. This must be given to the coach and school or sports official before return to activity.

All youth athletes and their parents/guardians must review information about Sudden Cardiac Arrest, then sign and return this form.
I

Parent/Guardian   Signature	Student Signature

Parent/Guardian Name [Print)	Student Name (Print)

Date	Date
Ohl•O I Department

I Department

of Health	Oh10	of Education