Important Information for Parents

. ALBUQUERQUE ACADEMY . MEDICAL FORM INSTRUCTION SHEET 2017-2018 School Year

PLEASE READ CAREFULLY BEFORE COMPLETING FORMS

Your child’s health and safety are as important to us as to you. Each year, following state and New Mexico Activities Association guidelines, we require physical examinations for all students. Participation in all our programs including experiential and physical education, interscholastic and intramural athletics, and other school activities depends upon completion of the medical forms. Please make an appointment with your health care provider as soon as possible after receiving this packet. Most health care providers require at least four weeks of scheduling time for physical exams.

The information contained within these forms will help us to provide more appropriate responses to your child's needs and will be shared only with members of our faculty and staff working with your child. If this physical examination requirement creates a financial hardship for your family, please call the school nurse, Jen Duvall, at 858-8876.

Please return the following forms by July 15th (for students returning to 8th through 12th grades, class schedules will be held until all forms are received or arrangements have been made with the school nurse):

Emergency Information Form This form must be completed and signed by the parent/guardian. Please mark any item “N/A” if it is not applicable to your child. List phone numbers (work, cellular, or pager) in order by which you would first prefer to be contacted in case of an emergency. For alternative emergency contacts, please select someone who is familiar with your child and within the Albuquerque area, if possible. Indicate your child’s insurance carrier. All students participating in athletics must have private insurance or purchase accident insurance through Albuquerque Academy. Information on accident insurance was included in your enrollment contract package. For further information on Albuquerque Academy Accident Insurance, contact the Albuquerque Academy Business Office at 828-3200. Please inform the school nurse of any changes in your child’s health, health care provider, or insurance carrier during the school year.

Consent for Over-the-Counter Medication Administration This form is to be completed if you would like your child to receive any over-the-counter medications from the school nurse for illnesses or injuries while at school. Students may carry and self-administer only a single dose per day of any over-the-counter medications. Any over-the-counter medication carried by a student must be kept in the original manufacturer’s container.

Medication Administration Form This form must be completed if your child will be taking or carrying any type of prescribed medications (i.e., Albuterol, Imitrex, Epi-Pens) longer than ten consecutive days on the Albuquerque Academy campus during the school year. For students using asthma medication at school, please sign and have your healthcare provider complete the Asthma Action Plan on the backside of the Medication Authorization Form. Students who take any type of controlled substance (e.g., Ritalin/Dexedrine) during school hours will not be allowed to carry or self-administer their medication. Arrangements must be made with the school nurse for medication administration. This form must be completed and signed by the parent/guardian and your health care provider if your child will be taking prescribed medication at school daily. If your child will be taking any prescription medications at school for ten days or less at any time during the school year, please contact the school nurse, Jen Duvall, at 858-8876.

Medical History and Physical Evaluation Form The Medical History section of this form is to be completed by the parent/guardian. The Physical Evaluation section of this form is to be completed by your health care provider. This form must be signed by your health care provider, a parent/guardian, and the student. The physical examination must be performed after April 1st (a New Mexico Activities Association requirement). We are required by law to maintain records of students’ previous immunizations. All immunizations must be up to date. Please provide copies of official documentation for any updates in your child's immunization record. If this is your child’s first year at Albuquerque Academy, official documentation of all immunizations must be submitted with this form. Your child will not be allowed to attend school without immunization records.

No student may attend classes, start practice, or travel on school trips until all forms are fully completed and returned to the school. Thank you for attending to this essential task.

. ALBUQUERQUE ACADEMY . STUDENT EMERGENCY INFORMATION FOR HEALTH ROOM, EXPERIENTIAL EDUCATION, FIELD TRIPS, INTERSCHOLASTIC ATHLETICS 2017-2018 School Year Grade Entering This form must be completed in its entirety for every student.

Student’s Name ______Date of Birth ______(Last) (First) (Middle)

Address ______Student’s Cell#______(Street) (City) (Zip Code)

Parent/Guardian ______Home Phone______1st Contact #______2nd Contact #______

My child has the following health conditions (e.g., diabetes, asthma, kidney problems, seizures, heart problems, etc.):______

______

My child has the following athletic injury or orthopedic condition: ______

Activity restrictions due to the above conditions: ______

My child has these allergies (medication, food, environmental [insect bites, pollen, latex]): ______

Severity of allergy (e.g., mild, moderate, anaphylactic) ______Previous hospitalization due to an allergic reaction:  YES  NO

My child has these dietary restrictions: ______

My child is now taking the following medication(s): ______(attach dosage instructions)

My child may take nonprescription pain medication administered outside of school nurse’s office (e.g., Tylenol [acetaminophen] or Advil [ibuprofen]):  YES  NO ______Indicate Preference

Date of last Tetanus Booster ______Please list your Albuquerque hospital preference: ______

Should questions arise regarding my child’s participation in or care during an activity, and parents/guardians are not available, please consult with:

1. Name ______Home Phone ______

Relationship to my child ______Work/Cellular/Pager ______/______/______

2. Name ______Home Phone ______

Relationship to my child ______Work/Cellular/Pager ______/______/______

Health Care Provider______Phone ______Dentist ______Phone ______

PARENTAL CONSENT: I/We hereby give my consent for ______to participate in interscholastic athletics and other school-sponsored or related activities at Albuquerque Academy and authorize Albuquerque Academy to provide the information as required on this form to the New Mexico Activities Association. The financial responsibility for securing care of injuries incurred while participating in school-sponsored activities is a matter between the parent(s)/guardian(s) and the health care provider. Albuquerque Academy may not pay doctors, dentists, or hospitals for any treatment of any child.

RELEASE OF MEDICAL INFORMATION: I/We authorize the release of any information contained on this form to faculty, staff, or volunteer members at Albuquerque Academy that may be working with my/our child.

INSURANCE: Albuquerque Academy requires that all students involved in athletics must be insured. -I/We have applied for student accident insurance through Albuquerque Academy.  YES  NO (Please check one) -I/We have accident insurance with another carrier: Insurance Co. ______Policy # ______Phone:______

Insurance Co. Address: ______Policy Holder’s Name:______

AUTHORIZATION FOR MEDICAL SERVICES: I/We request that I/we be contacted within a reasonable time in the event of illness or injury requiring medical services. In the event I/we cannot be reached, I/we parent(s)/guardian(s), hereby designate Experiential Education Faculty, School Nurse, Emergency Response Team, Athletic Director, Team Coach, Athletic Trainer, authorized chaperone or his/her designee to act in my/our behalf to authorize such hospitalization, medical attention and surgery as may be required in an emergency because of illness or injuries sustained by my/our child/ward while participating in school-sponsored activities. In the event I/we cannot be reached and the situation calls for medical attention, I/we recognize and relinquish our responsibility to a practicing physician and/or medical personnel acting in the best interest of my/our child/ward. I/We hereby assume financial responsibility for hospitalization, medical attention, emergency transportation and surgery provided.

______(Parent/Guardian Signature) (Date) . ALBUQUERQUE ACADEMY . CONSENT FOR OVER-THE-COUNTER MEDICATION ADMINISTRATION 2017-2018 School Year

The Albuquerque Academy Health Center has the following over-the-counter medications available as indicated below, which can be administered to your child for the treatment of acute illnesses or minor injuries. In order for these medications to be administered, it will be necessary for you to complete the following information. If you do not wish for your child to receive any of these medications, or would like to be contacted before the medication is given, please indicate what your preference is by checking the boxes below. For students with temperatures higher than 100° F, parents will be contacted and the student will be sent home. Students will not receive more than one dose of a specific medication per day nor will any medication be administered more than three consecutive days unless other arrangements have been made with the school nurse. If symptoms persist, parents will be consulted regarding follow-up care with their health care provider.

Student’s Name: ______Date of Birth ______

Parent/Guardian’s Name: ______Daytime Phone Number ______

Medical Conditions or Medical Treatments of Student: ______

______

Allergies (food, drug, environmental): ______

DO NOT GIVE DRUG CALL BEFORE ADMINISTERING YES NO Antacid/Antigas (calcium carbonate 675 mg; magnesium hydroxide 135 mg; simethicone 60 mg) – given for acid indigestion, heartburn Advil (ibuprofen) 200 to 400 mg – given for muscle aches, menstrual cramps, headaches, joint pain, fever, sore throat, or ear ache Tylenol (acetaminophen) 325 to 650 mg – given for muscle aches, menstrual cramps, headaches, joint pain, fever, sore throat, or ear ache Benadryl (diphenhydramine) 12.5 to 25 mg – given for mild to moderate allergic reactions such as rash, hives, runny nose, bug bites Claritin (loratadine) 10 mg – given for mild to moderate allergic reactions such as rash, hives, runny nose (only one dose per 24 hour period given) Decongestant (pseudoephedrine 30 mg; phenylephrine 10 mg) – given for sinus congestion Cough Drops (contains Menthol) – given as an oral pain reliever/cough suppressant Benadryl Cream – topical application of 2% diphenhydramine to be applied to local skin reactions (rashes, bug bites) Hydrocortisone Cream – topical application of 1% hydrocortisone to be applied to local skin reactions (rashes, bug bites) Arnica Gel – herbal medication applied topically to minor joint injuries and bruises or contusions

The Albuquerque Academy Health Center has my permission to administer the above medications (unless indicated above) to my child when necessary. Medications will not be administered without parental/guardian signature.

Parent/Guardian Signature ______Date ______

. ALBUQUERQUE ACADEMY . HEALTH CARE PROVIDER’S MEDICATION ORDER AND AUTHORIZATION FORM 2017-2018 School Year

For medication to be safely administered during school hours on the Albuquerque Academy campus please complete every item on this form. Please fill out a separate authorization form for each medication. If you have any questions, please call Jen Duvall, School Nurse, at 858-8876. FOR PRESCRIBED ASTHMA MEDICATION ONLY, PLEASE COMPLETE THE ASTHMA ACTION PLAN ON THE REVERSE SIDE OF FORM.

STUDENT’S NAME: ______DATE OF BIRTH______Please Print Last First

HEALTH CARE PROVIDER’S ORDER AND STUDENT COMPETENCY STATEMENT: 1. I have examined this student for (diagnosis) ______and have determined that he/she requires medication during school hours.

2. Name of medication: ______Dosage: ______

3. Time of administration:______Duration of administration (how long?):______

4. Please check this box if this medication is to be administered only when a morning dose of medication is forgotten at home (it is the parents’ responsibility to contact school nurse and request medication be given).

5. Special instructions regarding this medication: ______

6. Contact me if the following signs or symptoms appear:______

I believe this student is able to carry and administer her/his own medication (excluding controlled substances) at the appropriate time and in the appropriate way. Please check: ___ YES ___ NO

Health Care Provider Signature: ______Date: ______

Health Care Provider Name (print): ______Phone: ______

PARENT/GUARDIAN STATEMENT – please complete the appropriate statement below:

1. I/We, the undersigned parent(s)/guardian(s) of ______, believe he/she is competent to carry and administer his/her own medication (excluding controlled substances) at the appropriate time and in the appropriate way. I/We give my/our permission for him/her to do so. I/We agree that my/our child will carry the medication in a pharmacy labeled container with only the amount of medication required for the day. 2. I/We, the undersigned parent(s)/guardian(s) of ______, request that either the school nurse or a designated school employee administer the above medication according to the health care provider’s instructions. I/We agree to furnish the necessary prescribed medicine in the properly labeled container, to provide replacement medication as necessary, and I/we agree to notify the school nurse immediately if the health care provider or medication prescription is changed.

Parent/Guardian Signature: ______Date: ______

Home Phone: ______Work Phone: ______NEW MEXICO ASTHMA ACTION PLAN FOR SCHOOLS Date______School District ______School Name ______

School Nurse / Health Asst. ______School Phone # / FAX # ______/______

PARENT/GUARDIAN: Please complete the information in the top sections and sign consent at bottom of the page.

Student Name Date of Birth Student #

*Health Care Provider Name/Title Provider’s Office Phone / FAX # GREEN means Go! Use CONTROL medicine daily

Parent/Guardian Parent’s Phone #s YELLOW means Caution! Add Rescue medicine Emergency Contact Contact Phone #s RED means EMERGENCY! Allergies to Medications: Get help from a provider now!

Asthma Triggers Identified (Things that make your asthma worse): Date of student’s Date of Last Inhaler is kept: Exercise Colds Smoke (tobacco, fires, incense) Pollen Dust last visit to medical Flu Shot With Student Strong Odors Mold/moisture Stress/Emotions Pests (rodents, cockroaches) provider: In Classroom Gastroesophogeal reflux Season: Fall, Winter, Spring, Summer Health Office Animals______Other (food allergies):______/____/______/____/____ Other______HEALTH CARE PROVIDER: Please complete Severity Level, Zone Information and Medical Order Below

Asthma Severity: Intermittent or Persistent: Mild Moderate Severe

Green Zone: Go! Take Control Medications EVERY DAY You have ALL of these: No controller medication is prescribed. Always rinse mouth after using your daily inhaled medication.

• Breathing is easy ______, ______puff(s) MDI with spacer ______times a day • No cough or wheeze Inhaled corticosteroid or inhaled corticosteroid/long-acting -agonist • Can work and play ______, ______nebulizer treatment(s) ______times a day • No symptoms at night Inhaled corticosteroid

______, take ______by mouth once daily at bedtime Peak flow (optional): Leukotriene antagonist Greater than ≥ ______For asthma with exercise, ADD: (More than 80% of Personal Best) ______, ______puff(s) MDI with spacer 5 to 15 minutes before exercise For nasal/environmental allergy, ADD: Personal best peak flow: ______

Yellow Zone: Caution! Continue CONTROL Medicine & ADD RESCUE Medicines- You have ANY of these: DO NOT LEAVE STUDENT ALONE! Call Parent/Guardian when rescue medication is given.

• Cough or mild wheeze ______, ______puff(s) MDI with spacer & every_____ hours as needed • Tight chest Fast-acting inhaled -agonist • First signs of a cold OR • Problems sleeping, ______, ______nebulizer treatment(s) & every_____ hours as needed Playing or working Fast-acting inhaled -agonist Peak flow (optional): Other ______to ______Call your MEDICAL PROVIDER if you have these signs more than two times a week, or if your rescue (50% - 80% of Personal Best) medicine does not work! If symptoms are NOT better OR peak flow is NOT improved, go to RED ZONE↓

Red Zone: EMERGENCY! Continue CONTROL Medicine & ADD RESCUE Medicines and GET HELP! You have ANY of these: DO NOT LEAVE STUDENT ALONE! Call for emergency 911 and start treatment • Cannot talk, eat, or walk well ______, ______puff(s) MDI with spacer & every 20 minutes until paramedics arrive • Medicine is not helping or Fast-acting inhaled -agonist • Getting worse, not better OR • Breathing hard & fast ______,______nebulizer treatment(s) every 20 minutes until paramedics arrive • Blue lips & fingernails Fast-acting inhaled -agonist Peak flow (optional): Call 911 and start treatment immediately. Then call Parent/Guardian. Less than ≤ ______Use only if Oxygen and Pulse Oximeter available: (Less than 50% of Personal Best) Administer Oxygen ______l/min for 02 Sat. ≤ ______% and measure 02 Sat. every ______minutes HEALTH CARE PROVIDER ORDER AND SCHOOL MEDICATION CONSENT Parent/Guardian: Check all that apply: I approve of this asthma action plan. I give my permission for the school nurse and ____ Student has been instructed in the proper use of his/her asthma medications trained school personnel to follow this plan, administer medication(s), and contact and IS ABLE TO CARRY AND SELF-ADMINISTER his/her INHALER AT SCHOOL. my provider, if necessary. I assume full responsibility for providing the school with the prescribed medications and delivery and monitoring devices. I give my permission ____ Student is to notify designated school health personnel after using for the school to share the above information with school staff that need to know inhaler at school. and permission for my child to participate in any asthma educational learning

opportunities at school. ____ Student needs supervision or assistance when using inhaler.

SIGNATURE: ______DATE: ______Student is unable to carry his/her inhaler while at school.

*SIGNATURE/TITLE______DATE ______SCHOOL NURSE: ______DATE: ______IHP/EAP NANDA 00031 NIC-Periodically Assess the Effectiveness of the AAP and Asthma Education NOC- Patent Airway NMCOA - New Mexico Council on Asthma September 2012

. ALBUQUERQUE ACADEMY . PART A: Health History Form 2017-2018 School Year

This section must be completed prior to visiting your health care provider

Date of Exam

Name Date of birth

Sex Age Grade School Sport(s)

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to. GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in 26. Do you cough, wheeze, or have difficulty breathing during sports for any reason? or after exercise? 2. Do you have any ongoing medical conditions? If so, please 27. Have you ever used an inhaler or taken asthma medicine? identify below:  Asthma  Anemia  Diabetes 28. Is there anyone in your family who has asthma?  Infections 29. Were you born without or are you missing a kidney, an eye, a testicle 3. Other:Have you ever spent the night in the hospital? 30. (males),Do you h yourave groinspleen, pain or aorn ya otherpainful organ? bulge or hernia in the groin area? 4. Have you ever had surgery? 31. Have you had infectious mononucleosis (mono) within the last month? HEART HEALTH QUESTIONS ABOUT YOU Yes No 32. Do you have any rashes, pressure sores, or other skin problems? 5. Have you ever passed out or nearly passed out DURING or 33. Have you had a herpes or MRSA skin infection? AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or 34. Have you ever had a head injury or concussion? pressure in your chest during exercise? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? 7. Does your heart ever race or skip beats (irregular beats) during 36. Do you have a history of seizure disorder? 8.exercise? Has a doctor ever told you that you have any heart 37. Do you have headaches with exercise? problems? If so, check all that apply: 38. Have you ever had numbness, tingling, or weakness in your arms  High blood pressure  A heart murmur or legs after being hit or falling?  High cholesterol  A heart infection 39. Have you ever been unable to move your arms or legs after being hit or falling?  Kawasaki disease Other: 40. Have you ever become ill while exercising in the heat? 9. Has a doctor ever ordered a test for your heart? (For example, 41. Do you get frequent muscle cramps when exercising? ECG/EKG, echocardiogram) 42. Do you or someone in your family have sickle cell trait or disease? 10. Do you get lightheaded or feel more short of breath than expected during exercise? 43. Have you had any problems with your eyes or vision? 11. Have you ever had an unexplained seizure? 44. Have you had any eye injuries? 12. Do you get more tired or short of breath more quickly than 45. Do you wear glasses or contact lenses? your friends during exercise? 46. Do you wear protective eyewear, such as goggles or a face shield? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 47. Do you worry about your weight? 13. Has any family member or relative died of heart problems or 48. Are you trying to or has anyone recommended that you gain had an unexpected or unexplained sudden death before age 50 or lose weight? (including drowning, unexplained car accident, or sudden infant 49. Are you on a special diet or do you avoid certain types of foods? 14.de Doesath asyndrome)?nyone in your family have hypertrophic cardiomyopathy, 50. Have you ever had an eating disorder? Marfan syndrome, arrhythmogenic right ventricular 51. Do you have any concerns that you would like to discuss with a doctor? cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic FEMALES ONLY 15.ventricular Does anyone tachycardia? in your family have a heart problem, 52. Have you ever had a menstrual period? pacemaker, or implanted defibrillator? 53. How old were you when you had your first menstrual period? 16. Has anyone in your family had unexplained fainting, 54. How many periods have you had in the last 12 months? unexplained seizures, or near drowning? Explain “yes” answers here BONE AND JOINT QUESTIONS Yes No 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? 18. Have you ever had any broken or fractured bones or dislocated 19.joints? Ha ve you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? 20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome 22.or Do dwarfism) you regularly use a brace, orthotics, or other assistive device? 23. Do you h a ve a bone, mus c le, or joint inju r y th a t bothers you? 24. Do a n y of your joints become painful, s wollen, feel warm, or look 25.red? Do you have any history of juvenile arthritis or connective tissue disease?

. ALBUQUERQUE ACADEMY . . ALBUQUERQUE ACADEMY . PART B: Student Physical Evaluation PART C: Health Care Provider’s Statement and Parental Release Statement 2017-2018 School Year 2017-2018 School Year

THIS SECTION OF THE FORM IS TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER THIS PAGE MUST BE SIGNED BY YOUR HEALTH CARE PROVIDER, A PARENT/GUARDIAN, AND THE STUDENT

Name Date of Birth Date of Exam HEALTH CARE PROVIDER’S STATEMENT EXAMINATION

Height : Weight : BMI %ile: Male Female I certify that I have, on this date, reviewed the history and examined this student and that on the basis of the examination BP( / ) B/P %ile: Pulse: Vision R 20/ L 20/ Corrected Y N requested by the school authorities and the student’s medical history as furnished to me, it is permissible for this student to MEDICAL NORMAL ABNORMAL FINDINGS participate as indicated below. I have also discussed any questions the parent(s)/guardian(s) and student may have Appearance • Marfan stigmata (kyphoscoliosis, high-arched, palate, pectus excavatum, arachnodactyly, arm span>height, regarding participation in interscholastic activities. hyperlaxity, myopia, MVP, arotic insufficiency) 1. Cleared for all classifications ______Eyes/ears/nose/throat • Pupils equal Cleared after completing evaluation/rehabilitation for: ______• Hearing NOT cleared for: Contact Sports: Lymph nodes Contact/Collision _____ Heart a • Murmurs (auscultation standing, supine, +/- Valsalva) Limited Contact _____ • Location of point of maximal impulse (PMI) Non-Contact Sports: Strenuous _____ Pulses • Simultaneous femoral and radial pulses Non-Strenuous _____ Lungs Abdomen 2. Immunizations are current ______(Please attach a copy of the immunization record if the student is Genitourinary (males only)b new to Albuquerque Academy or if any additional immunizations have been given. See the back of this form Skin • HSV, lesions suggestive of MRSA, tinea corporis for a copy of the returning student's current immunization record.)

c Neurologic Health Care Provider Name (Please Print) ______MUSCULOSKELETAL Neck Health Care Provider Signature______Date ______Back Shoulder/arm Health Care Provider Address______Phone ______Elbow/forearm Wrist/hand/fingers ACKNOWLEDGMENT OF INJURY RISKS, Hip/thigh MATURITY STATEMENT FOR CONTACT SPORTS, Knee AND PERSONAL MEDICATION NOTIFICATION Leg/ankle Foot/toes 1. I/We, the parent(s)/guardian(s) and the student, are aware that preparation for and participation in interscholastic Functional • Duck-walk, single leg hop athletics involves many risks of serious and permanent injury to the student-athlete. We understand and acknowledge aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. the danger of these severe injuries as inherent in any physical activity that may involve vigorous physical contact. We bConsider GU exam if in private setting. Having third party present is recommended. also understand that the likelihood of injury increases in contact sports in those students who are not of a comparable cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. physical maturity level with other participants. We have discussed any concerns we may have about our child’s maturity level with our health care provider. Samples of Classification of sports by contact: 2. I/We, the parent(s)/guardian(s) and the student, hereby state that the medical history has been reviewed and that the questions are accurate to the best of our knowledge. We have also completely read, understand, and agree to all of the Contact Non-Contact Contact/Collision: Strenuous: above mentioned statements and their content. Football Dance 3. I/We, the parent(s)/guardian(s) give permission for any information contained within this form to be shared with faculty or Soccer Field: Discus, Javelin, Shot-put Wrestling Running, swimming, weight lifting staff members of Albuquerque Academy working with my/our child. Limited Contact: Tennis Baseball/Softball Experiential Education: Student Signature ______Date ______Basketball Hiking, rock climbing, canoeing, Diving Backpacking, snowshoeing, ropes course Volleyball Non-strenuous: Field: High Jump, Pole Vault Golf, bowling Parent/Guardian Signature ______Date ______

THIS SECTION OF THE FORM IS TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER THIS PAGE MUST BE SIGNED BY YOUR HEALTH CARE PROVIDER, A PARENT/GUARDIAN, AND THE STUDENT

Name Date of Birth Date of Exam HEALTH CARE PROVIDER’S STATEMENT EXAMINATION

. ALBUQUERQUE ACADEMY . . A LBUQUERQUE ACADEMY . PART D: Immunization History PART A: Health History Form 2017-2018 School Year 2017-2018 School Year

This section must be completed prior to visiting your health care provider IMMUNIZATION HISTORY FOR Name Date of Birth Age Sex Entering Grade Sport(s) in which you are likely to participate in Medicines: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking:

Allergies: Do you have any allergies? Yes No If yes, please identify specific allergy below: Medicines Pollens Food Stinging Insects

GENERAL QUESTIONS Yes No MEDICAL QUESTIONS YES NO 1. Has a doctor ever denied or restricted your participation in sports 26. Do you cough, wheeze, or have difficulty breathing during or after for any reason? exercise? 2. Do you have any ongoing medical conditions? 27. Have you ever used an inhaler or taken asthma medicine? Asthma Anemia Diabetes 27.28. IsHave there you anyo everne in used your anfam inhalerily who orha takens asthm asthmaa? medicine? Infections Other: 28. Is there anyone in your family who has asthma? 3. Have you ever spent the night in the hospital? 29. WereWere you you born born without without or areor areyou youmissing missing a kidney, a kidney, an eye, an eye, 4. Have you ever had surgery? a testicle (males), (males), your your spleen, spleen, or any or anyother other organ? organ? 30. Do you have groin pain or a painful bulge or hernia in the HEART HEALTH QUESTIONS ABOUT YOU Yes No 30. Do you have groin pain or a painful bulge or hernia in the groin area? groin area? 5. Have you ever passed out or nearly passed out DURING or 31. Have you had infectious mononucleosis (mono) within the last month? 331.1. HavHavee yo youu ha hadd inf einfectiousctious mononu mononucleosiscleosis (mono )(mono) within th withine last mtheonth ? AFTER exercise? 32. Have you ever had MRSA a skin infection? 31. Have you had infectious mononucleosis (mono) within the last last month? 6. Have you ever had discomfort, pain, tightness, or pressure in problems? month? your chest during exercise? 33. Do you have any rashes, pressure sores, or other skin problems?

7. Does your heart ever race or skip beats (irregular beats) during exercise? 34. Have you ever had a head injury or concussion?

8. Has a doctor ever told you that you have any heart problems? If 35. Have you ever had a hit or blow to the head that caused confusion, so, check all that apply: High blood pressure A heart murmur a prolonged headache, or memory problems? 36. Do you have a history of seizure disorder? High cholesterol A heart infection 36. Do you have a history of seizure disorder? Kawasaki disease Other: 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 37. Do you have headaches with exercise?

10. Do you get lightheaded or feel more short of breath than 38. Have you ever had numbness, tingling, or weakness in your arms or expected during exercise? 11. Have you ever had an unexplained seizure? legs after being hit or falling? 39. Have you ever been unable to move your arms or legs after 12. Do you get more tired or short of breath more quickly than your 39. Have you ever been unable to move your arms or legs after being friends during exercise? being hit or falling? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 40. Havehit or falling?you ever become ill while exercising in the heat?

13. Has any family member or relative died of heart problems or had an 40.41. HaveDo you you get ever frequent become muscle ill while exercisingcramps when in the exercising? heat? unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death 41.42. Do you getor someone frequent inmuscle your familycramps have when sic exercising?kle cell trait or syndrome)? 41. Do you get frequent muscle cramps when exercising? 42. disease? Do you or someone in your family have sickle cell trait or 14. Does anyone in your family have hypertrophic cardiomyopathy, 42. Do you or someone in your family have sickle cell trait or Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, disease? long QT syndrome, short QT syndrome, Brugada syndrome, or 43. disease?Have you had any problems with your eyes or vision? catecholaminergic polymorphic ventricular tachycardia? 43. Have you had any problems with your eyes or vision? 40. Have you ever become ill while exercising in the heat? 15. Does anyone in your family have a heart problem, pacemaker, 44. Have you had any eye injuries? or implanted defibrillator? 41. Do you get frequent muscle cramps when exercising? 45. Do you wear glasses or contact lenses? 16. Has anyone in your family had unexplained fainting, 42. Do you or someone in your family have sickle cell trait or disease? unexplained seizures, or near drowning? 46. Do you wear protective eyewear? Goggles or a face shield? 43. Have you had any problems with your eyes or vision? 44. Have you had any eye injuries? BONE AND JOINT QUESTIONS Yes No 47. Do you worry about your weight? 45. Do you wear glasses or contact lenses? 17. Have you ever had an injury to a bone, muscle, ligament, or 48. Are you trying to or has anyone recommended that you gain tendon that caused you to miss a practice or a game? 46. Do you wear protective eyewear, such as goggles or a face shield? or lose weight? 47. Do you worry about your weight? 18. Have you ever had any broken or fractured bones or dislocated joints? 49. Are you on a special diet or do you avoid certain types of food?

19. Have you ever had an injury that required x-rays, MRI, CT 50. Have you ever had an eating disorder? scan, injections, therapy, a brace, cast, or crutches? 40. Have you ever become ill while exercising in the heat? 42. Do you or someone in your family have sickle cell trait or disease? 41. Do you get frequent muscle cramps when exercising? Health Facility 20. Have you ever had a stress fracture? . 51 Do you have any concerns that you would like to discuss with a Doctor? Jen Duvall, CFNP, RN, MSN, MPH 21. Have you ever been told that you have or have you had an x-ray for 43. Have you had any problems with your eyes or vision? 42. Do you or someone in your family have sickle cell trait or disease? neck instability or atlantoaxial instability? (Down syndrome or (505) 858-8876 FEMALES ONLY 44. Have you had any eye injuries? 43. Have you had any problems with your eyes or vision? dwarfism) 52. Have you ever had a menstrual period?______If so what age were you______(505) 858-8886 – fax 45. Do you wear glasses or contact lenses? 44. Have you had any eye injuries? 22. Do you regularly use a brace, orthotics, or any other assistive device? 53. How many periods have you had in the last 12 months?______Email: [email protected] 46. Do you wear protective eyewear, such as goggles or a face shield? 45. Do you wear glasses or contact lenses? 23. Do you have a bone, muscle, or joint injury that bothers you? Explain “Yes” answers here: 47. Do you worry about your weight? 46. Do you wear protective eyewear, such as goggles or a face shield?

6400 Wyoming Blvd NE  Albuquerque, NM 87109 24. Do any of your joints become painful, swollen, feel warm, or look red? 47. Do you worry about your weight? 25. Do you have any history of juvenile arthritis or connective tissue 41. Do you get frequent muscle cramps when exercising? disease?