GILBERT HIGH SCHOOL

PRE-PARTICIPATION PACKET FOR ATHLETICS Educational Information found at gilbertathletics.org under Sports Medicine tab

Full Pre-Participation Packets are available at GHS

The GHS Pre-participation Packet for Athletics contains important information regarding health & safety that should be reviewed by athletes and their parents prior to athletic participation at GHS or GMS. Checklist 1. Online @ gilbertathletics.org for your review:

● Parent letter regarding sports medicine services ● Information regarding GHS athletic training staff and team physicians ● Educational information regarding concussion, sickle cell trait, common skin infections, sudden

cardiac death, heat illness, proper tackling technique, blood hygiene, nutrition, dietary supplements, and energy drinks

● Instructions for creating an account, completing required digital pre-participation forms, and uploading the completed SCHSL Physical Exam Form on PlanetHS.com

2. Print SCHSL Physical form. Take form with you to exam to be cleared by healthcare provider. 3. PlanetHS – New athletes and parents should create a PlanetHS account. Returning athletes and parents should log into an existing PlanetHS account. All athletes and parents should complete required digital pre-participation forms.

● Forms to be completed digitally on PlanetHS.com (you can choose to REUSE previous years

forms- see form “Returning (student/parent) Athletic Pre-Participation Forms Registration”) o Pre-participation Physical Exam History Form (Print to take with you when you go to

have physical examination completed by Healthcare professional) o Parent’s Permission & Acknowledgement of Risk for Son/Daughter to Participate in

Athletics o Concussion Acknowledgement and Signature Form o Consent and Medical Information Form

● Forms to be uploaded to Planeths.com(upload a picture or scanned document)

o Pre-participation Physical Examination form (back page of physical that should be completed, dated, and signed by healthcare professional)

o Birth Certificate ● GMS Students please select GHS as “OTHER” school

DearParent:AsGilbertHighSchool’sheadathletictrainer,Iamresponsibleforcoordinationsportsmedicine/athletictrainingservicesforGHSathletes.Oursportsmedicineprogram’sfocusistoprevent,evaluate,treat,andrehabilitateinjuriesincurredbyGHSathletesduringthecourseofpracticeandcompetition.Attachedareafewremindersthathelpusserveyourathletebotheffectivelyandefficiently.PRE-PARTICIPATIONPAPERWORK:Allathletesarerequiredtocompleteandsubmitpre-participationformsonPlaneths.combeforebeingallowedtoparticipationinathletics,includingtry-outsandstrength/conditioningsessions.SCHSLrequiresaphysicaltobeconductedafterApril1st,2021forathleticparticipationin2021-2022schoolyear.ATHLETICINJURIES:Intheeventyourstudent-athletebecomesinjuredduringtheseason,he/sheshouldscheduleanappointmenttobeseenbyaGilbertHighSchoolathletictrainer.Pleaseusethewebaddress,https://gilbertsportsmedicine.setmore.com/,orvisitGilbertAtheltics.organdlookundertheIndiansSportsMedicineTab.Theathletictrainingroomisopenforinjuryevaluationsandtreatmentsthroughouttheschoolday(byappointment)andafterschoolat3:20pm.InmostcasesourATstaffcanhandletheinjurywithoutareferraltoaphysicianoremergencyroom.TheIndiansportsmedicineprogramalsooffersrehabservicesforsportsinjuriessustainedduringparticipationwithatGHS/SCHSL–sanctionedteam.PhysicianReferrals:Whenaphysicianreferralisneeded,wecanassistwiththearrangementoftheappointment.PrismaOrthopedicsservesastheteamphysiciansforourathleticsprograms.Typicallywecanarrangeanappointmentwithin24hours.Ifyouprefertoseeanotherphysician,wemaybeabletoassistwiththatappointmentaswell.Anytimeaphysicianexaminesanathlete,he/sheshouldreturnwithwrittendocumentationfromthedoctorincludingthediagnosis,recommendations,andrestrictionsforathleticparticipation.Pleasereturnthisdocumenttotheathletictraineruponreturningtoschool.ATHLETICACCIDENTINSURACNE:Whileanathlete’sparentisultimatelyresponsibleformedicalbillsincurredbecauseofinjury/illnessduringathleticparticipation,Lexington1doesprovidesecondaryathleticaccidentinsuranceforathleteswhoareinjuredwhileparticipatinginofficialteamfunctions.Thepolicyisintendedtobean“excess”policydesignedtopaysecondarilytotheathlete’sprimaryhealthinsurance.Parentsofaninjuredathlete,whohasbeenreferredtoaphysicianbyastaffathletictrainer,shouldreceiveaclaimform.Theparentshouldcompletetheclaimformandfollowthedirectionstofiletheclaim.Parentsarestronglyencouragedtomakeaphotocopyofthecompletedclaimformfortheirrecords.Intheeventanathleteseesaphysicianforaninjury,butwasnotreferredbyastaffathletictrainer,theathlete’sparentsshouldcontacttheheadathletictrainerASAP.Failuretodosomayresultinaclaimnotbeingfiled.Allclaimsmustbefiledwithin90daysofinjury.INJURIESDURINGAGAME:Intheunfortunateeventthatyourathleteisinjuredduringagame,pleaseremaininthestands.Iunderstandthatthismaybedifficult,butafranticparentrushingthefieldonlystirsemotionsintheinjuredathlete,whichcanmakeassessmentandcareoftheinjurymoredifficult.Aftertheinjuryisevaluatedandinitialtreatmentisprovided,theparentwillbecalledtothesideline/athletictrainingroomtobeinformedofthenatureoftheinjuryalongwithrecommendationsforcare.IndianSportsMedicineiscommittedtoprovidingGHSathleteswiththebestathletichealthcarepossible.PleasecallifyouhaveanyquestionsorconcernsByronMillwood,MS,ATC/SCATHeadAthleticTrainer,GilbertHighSchoolPhone:803-821-1985Fax:803-821-1938Email:bmillwood@lexington1.netFormoreinformationaboutourSportsMedicineProgrampleasevisithttp://gilbertathletics.org

Medical Normal Abnormal Findings

Appearance: Marfan stigmata (kyphoscoliosis, high–arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse (MVP), and aortic insufficiency

Eyes / Ears / Nose / 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

Neurologic

Musculoskeletal:

- Neck

- Back

- Shoulders/Arm

- Elbow/Forearm

- Wrist/Hand/Fingers

- Hip/Thighs

- Knees

- Leg/Ankles

- Foot/Toes

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

___________________________________________________________ _________________________ Last Name First Name Middle Initial Date of Birth

Examination

Height: Weight:

BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected ___ Yes ___ No

Consider: electrocardiography (ECG), echocardiography, and referral to cardiologist for abnormal cardiac history or examination findings or a combination of those.

Preparticipation Physical Evaluation ___ Medically eligible for all sports without restriction.

___ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of: ________________________ ___________________________________________________________________________________________________________________

___ 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 preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. If conditions arise after the athlete had 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: _________________

Address: _________________________________________________________________________Phone: ____________________

Signature of health care professional: ___________________________________________________________ MD, DO, 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 od Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Name: _________________________________________________________ Date of Birth: _____________________________ Sex: _____ Date of Examination: __________________________ Sport(s): ___________________________________________________________________

List past and current medical conditions: ____________________________________________________________________________________ ______________________________________________________________________________________________________________________

Have you ever had surgery? If yes, list all past surgical procedures: ________________________________________________________________ ______________________________________________________________________________________________________________________

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional): _______________ ______________________________________________________________________________________________________________________

Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects): ______________________________ ______________________________________________________________________________________________________________________

General Questions. Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.

Yes

No

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?

Heart Heath Questions About You Yes No

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 ordered a test for your heart? (for example Electrocardiography (ECG) or echocardiography.

9. Do you get lightheaded or feel shorter of breath than your friends during exercise?

10. Have you ever had a seizure?

Health Questions About Your Family Yes No

11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car accident)?

12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogen- ic right ventricular cardiomyopathy (ARVC), long QTsyndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?

13. Does anyone in your family had a pacemaker or implanted Defibrillator before age 35?

Bone and Joint Questions Yes No

14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint or tendon that caused you to miss a game or practice?

15. Do you have a bone, muscle, ligament or joint injury that bothers you?

Medical Questions Yes No

16. Do you cough, wheeze, or have difficulty breathing during or after exercise?

17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

20. Have you ever had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

21. Have you ever had numbness, tingling, or weakness in your arms or leg, or been unable to move your arms or legs after being hit or falling?

22. Have you ever become ill while exercising in the heat?

23. Do you or someone in your family have sickle cell trait or disease?

24. Have you ever had or do you have any problems with your eyes or vision?

25. Do you worry about 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 certain types of foods?

28. Have you ever had an eating disorder?

Females Only Yes No

29. Have you ever had a menstrual period?

30. How old were you when you had your first menstrual period?

31. When was your most recent menstrual period?

32. How many periods have you had in the past 12 months?

Explain a “Yes” answer here: _________________________________________ _________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

© 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 od Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement.

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of athlete: _________________________________________________________________________

Signature of parent or guardian: ________________________________________________________________

Date _______________________

S. Wendell Holmes Jr., MD, is the team physician for Gilbert High School.Call his o� ce at 803-296-9260.

803-29ORTHO | PHUSCOrthoCenter.org

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everyone in between. And we’ll guide every step of your treatment — from diagnosis to recovery —

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Put our innovation to work for you. Find your specialist today.

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Christopher G. Mazoué, MD

O� cial team physicians for the USC Gamecocks

Re

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If you

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6. C

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