Pre-Participation Health Examination Form, Updated July, 2014 UIHSAA PARTICIPATION AMINATIO! Instructions for completing pre-participation (athletic) Health Examination and Consent Form 1. PLEASE TYPE OR PRINT LEGIBLY 2. Parent/Guardian along with the student are to complete the Health History on page 3 and the Disclosure and Consent Document on page 2. Please note student and parent are to sign both forms. The Health History is to be taken to the physical examination for the physician/provider to review. 3. Physician/Provider is to complete and sign the Physical Examination form on page 4. 4. Entire completed form is to be returned to school administration. 1, School personnel should review form to assure it is completed properly. 2. ORIGINAL copy is to be retained in school files. A health examination must be performed annually and the Pre-participation Physical Evaluation Form must be completed before any student may participate in athletic activities sponsored by this Association. A Pre-participation Physical Evaluation Form along with the Disclosure and Consent Document must be on file at the school before any participation in athletic activities. ‘The health examination may be completed and the form signed by any Medical Doctor (MD), Doctor of Osteopathy (DO), Physician’s Assistant (PAC), Chiropractic Physician (DC), or Registered Nurse Practitioner (RNP) functioning within the legal scope of their practice. THE UTAH HIGH SCHOOL ACTIVITIES ASSOCIATION DOES NOT PROVIDE PRINTED COPIES OF THIS FORM. PLEASE MAKE ALL NECESSARY COPIES. Page 1 of 4@ PREPARTICIPATION PHYSICAL EVALUATION PHYSICAL EXAMINATION FORM nom Seremy ke stre owaien I KH Zo PHYSICIAN REMINDERS 1. nl ttn csr on mare ete aus * Doytu ested ur dalle pss? 1 Doyen a a pon ese, os? 1 Doyot ee tyre reo? ow Yoon ed cura heigl Dang pst 0 ap use einem nh 5? yok aah ar any he us? iv yoo arabe sas rsd yar pernc pane? {Her en ary sere nip yao wa oro Your prone? 4 Dyn wer ast bt ents ue pnon? 2, Cie vogue on clear spans nso S14. a at Wot o Lise ovexes at tana pst Nh ached pe pc eat, cn i aN et aaron ren = Pope = ea = thomas auton stn, i-th) > tna epi mae nn Pi) Pees + Seto om al al pls ay eon in i is arse hac = era High [I cna Dusk a lot Se enero acres wernt oem ‘Shae et one tnmaay se iy pent cme aed orl ts woe eared oral pts wiotreticin wth eames ute ati etme er 1 Pong ter use 1 Foray spo 1 Forcast ecmedtire ‘have rained the abore-ane student and compete he prprticpton phys vation, The thle des not preset apace cnc! entinaions oa and apt the spa ined abo. Acpy fh phytate on erin my alle nd can de aa each! a equate ane os tos ie fer he hte as ben ceed presto, te pyr sn aie erates it ae poem ale ents pte soangectees secon mvormameny dan Atk, PA-C fafa oe BO WiTpend fl #10. : SYrcwsbiney lack ut S40 %h fis- 913-000 Sie een (©2010 rican ay of Fy Pcs Aan ay Pet Avi Calo Spats Mans Aran Nadel iy Spats Med fan Ooo Sty Spars Mode, an Arian Cotscptic zeny of rs Nec, Piss ras epi ancamnec acto upsell, Page 4 of 4