MEDICAL QUESTIONS
	Yes
	No
	
26.	Doyoucough, wheeze,or have difficulty breathingduringor after exercise?
			
27.	Haveyou ever usedaninhaler or taken asthma medicine?
			
28.	Is there anyone in your family who has asthma?
			
29.	Wereyouborn without or areyoumissingakidney, an eye, atesticle (males),
			
your spleen,or any other organ?
			
30.	Doyou havegroinpainor apainful bulge or herniainthe groinarea?
			
31.	Haveyou hadinfectious mononucleosis (mono) within the pastmonth?
			
32.	Doyou haveany rashes,pressuresores,or other skinproblems?
			
33.	Haveyou hada herpes (coldsores) or MRSA (staph) skininfection?
			
34.	Haveyou ever hada headinjury or concussion?
			
35.	Haveyou ever hada hitor blow totheheadthatcausedconfusion,
			
prolonged headaches,or memory problems?
			
36.	Doyou have a history ofseizure disorder or epilepsy?
			
37.	Doyou haveheadaches withexercise?
			
38.	Haveyou ever hadnumbness,tingling,or weakness inyour arms or
			
legs after being hitor falling?
			
39.	Haveyou ever been unable tomoveyour arms or legs after beinghit or falling?
			
40.	Haveyou ever become ill whileexercisingintheheat?
			
41.	Doyou getfrequent musclecramps whenexercising?
			
42.	Doyou or someoneinyour family havesicklecell traitor disease?
			
43.	Haveyou hadany problems withyour eyes or vision?
			
44.	Haveyou hadaneyeinjury?
			
45.	Doyou wear glasses or contactlenses?
			
46.	Doyou wear protectiveeyewear,such as goggles or a face shield?
			
47.	Doyou worry aboutyour weight?
			
48.	Areyoutryingtogain or loseweight? Has anyone recommended that you do?
			
49.	Areyouonaspecial dietor doyouavoidcertaintypes offoods?
			
50.	Haveyou ever hadaneatingdisorder?
			
51.	Doyou haveany concerns thatyouwouldliketodiscuss witha doctor?
			
FEMALES ONLY
		
52.	Haveyou ever hada menstrual period?
		
53.	How oldwereyouwhenyou hadyour firstmenstrual period?
		
54.	How many periods haveyou hadinthelast12months?
		
Ohio High School Athletic Association

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 1 of6 HISTORY FORM – Please be advised that this paper form is no longer the OHSAA standard.
(Note: This form is to be filled out by thestudent and parent prior to seeing the medical examiner.)

Date of Exam _________________________________________________________________________________________________________________________________________ Name ___________________________________________________________________________________________________ Date of birth ________________________________ Sex _________ Age _________ Grade ___________ School ___________________________________________________Sport(s)     _____________________________________ Address _____________________________________________________________________________________________________________________________________________
Emergency Contact: _________________________________________________________________________________________ Relationship ___________________________________ Phone (H) __________________________ (W) _________________________ (Cell) __________________________(Email) _____________________________________________________

Medicines and Allergies: Please list the prescription and over-the-counter medicines and supplements (herbal and nutritional-including energy drinks/ protein supplements) 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” answersbelow.Circle questions you don’tknow theanswers to.
GENERAL QUESTIONS
	Yes
	No
		BONE AND JOINT QUESTIONS- CONTINUED
	Yes
	No
	
1.	Has adoctor ever denied or restrictedyour participationinsports for any reason?
				22.	Doyouregularly useabrace,orthotics,or other assistivedevice?
			
				23.	Doyou havea bone, muscle,or jointinjury that bothers you?
			
2.	Doyou haveany ongoingmedical conditions?Ifso, pleaseidentify below:	Asthma	Anemia	Diabetes	Infections Other: _________________________________________________
				24.	Doany ofyour joints becomepainful,swolllen,feel warm, or look red?
			
				25.	Doyou haveany history ofjuvenilearthritis or connectivetissuedisease?

Explain "yes" answershere
	
3.	Haveyou ever spentthenight inthe hospital?
				
4.	Haveyou ever hadsurgery?
				
HEART HEALTH QUESTIONS ABOUT YOU
	Yes
	No
		
5.	Haveyou ever passedoutor nearly passed out DURING or AFTER exercise?
				
6.	Have you ever had discomfort,pain,tightness,or pressure in your chest during exercise?
				
7.	Does your heartever raceor skipbeats (irregular beats) duringexercise?
				
8.	Has adoctor ever toldyouthatyou haveany heartproblems?Ifso,check all thatapply:
□Highbloodpressure                 □ A heartmurmur □Highcholesterol                      □ A heartinfection
□Kawasaki disease	Other: __________________________
				
9.	Has adoctor ever orderedatestfor your heart?(For example, ECG/EKG, echocardiogram)
				
10.	Doyou getlightheadedor feel moreshortofbreaththanexpectedduring exercise?
				
11.	Haveyou ever hadanunexplainedseizure?
				
12.	Doyou getmoretiredor shortofbreathmore quickly thanyour friends during exercise?
				
HEART HEALTHQUESTIONS ABOUT YOURFAMILY
	Yes
	No
		
13.	Has any family member or relativediedofheartproblems or hadan unexpected or unexplained sudden death before age 50 (including drowning,unexplained car accident,or sudden infantdeath syndrome)?
				
14.	Does anyoneinyour family havehypertrophic cardiomyopathy,Marfan syndrome,arryhthmogenic right ventricular cardiomyopathy,longQT syndrome,shortQT syndrome,Brugadasyndrome,or catecholaminergic polymorphic ventricular tachycardia?
				
15.	Does anyoneinyour family havea heartproblem, pacemaker,or implanted defibrillator?
				
16.	Has anyoneinyour family hadunexplainedfainting,unexplainedseizures, or near drowning?
				
BONE AND JOINT QUESTIONS
	Yes
	No
		
17.	Haveyou ever hadaninjury toabone, muscle,ligament,or tendonthat causedyoutomiss apracticeor game?
				
18.	Haveyou ever hadany brokenor fractured bones or dislocated joints?
				
19.	Haveyou ever hadaninjury thatrequiredx-rays,MRI, CT scan,injections, therapy, a brace, a cast, or crutches?
				
20.	Haveyou ever hada stress fracture?
				
21.      Haveyou ever been toldthatyouhaveor haveyouhadanx-ray for neck instability or atlantoaxial instability?(Downsyndromeor dwarfism)

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

Signature of Student________________________________________________Signature of parent/guardian____________________________________________________________Date: ________________________

The student has family insurance	Yes	No Ifyes, family insurance company name and policy number: _____________________________________________________________________________.

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

Ohio High School Athletic Association

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 2 of6 THE ATHLETE WITH SPECIAL NEEDS - SUPPLEMENTAL HISTORY FORM

PLEASE COMPLETE ONLY IF YOUR STUDENT HAS SPECIAL NEEDS OR A DISABILITY.

Date of Exam _________________________________________________________________________________________________________________________________________

Name ___________________________________________________________________________________________________ Date of birth ________________________________ Sex _________ Age _________ Grade _______________ School ___________________________________________________Sport(s)     _____________________________________

1.	Typeof disability
	
2.	Dateofdisability
	
3.	Classification(ifavailable)
	
4.	Causeofdisability (birth,disease,accident/trauma,other)
	
5.	Listthe sports you are interested in playing
	
	Yes
	No
	
6.	Doyouregularly useabrace,assistivedeviceor prosthetic?
			
7.
	Doyou useaspecial brace or assistive device for sports?
			
8.
	Doyou haveany rashes,pressuresores,or any other skinproblems?
			
9.
	Doyou havea hearingloss?Doyouuseahearingaid?
			
10.
	Doyou haveavisual impairment?
			
11.
	Doyou haveany special devices for bowel or bladder function?
			
12.
	Doyou haveburning or discomfortwhenurinating?
			
13.
	Haveyou hadautonomic dysreflexia?
			
14.
	Haveyou ever been diagnosedwith aheatrelated(hyperthermia) or cold-related(hypothermia) illness?
			
15.
	Doyou havemusclespasticity?
			
16.
	Doyou havefrequentseizures that cannot becontrolledby medication?

Explain "yes" answershere

Pleaseindicateif you have ever had anyof the following.

	Yes
	No
	
Atlantoaxial instability
			
X-ray evaluationfor atlantoaxial instability
			
Dislocatedjoints (morethanone)
			
Easy bleeding
			
Enlargedspleen
			
Hepatitis
			
Osteopenia or osteoporosis
			
Difficulty controllingbowel
			
Difficulty controllingbladder
			
Numbness or tinglinginarms or hands
			
Numbness or tinglinginlegs or feet
			
Weakness inarms or hands
			
Weakness inlegs or feet
			
Recentchange incoordination
			
Recentchange inability towalk
			
Spinabifida
			
Latex allergy

Explain "yes" answershere

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

Signature of Student________________________________________________Signature of parent/guardian____________________________________________________________Date: ________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

Ohio High School Athletic Association

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 3 of6 PHYSICAL EXAMINATION FORM
Name ___________________________________________________________________________________________________ Date of birth ________________________________

PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues. · Do you feel stressed out or under a lot of pressure?
· Do you ever feelsad, hopeless, depressed or anxious? · Do you feel safe at your home or residence?
· Have you evertried 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 evertaken anabolic steroids or used any other performance supplement?
· Have you evertaken any supplements to help you gain or loseweight or improve your performance? · Do you wear aseat belt, use a helmet or use condoms?
· Do you consume energy drinks?
2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).

EXAMINATION	DATE OF EXAMINATION ______________________________
	
Height	Weight	□ Male	□ Female
	
BP	/	(	/	)	Pulse	Vision R 20/	L20/	Corrected	□ Y     □ N
	
MEDICAL
	NORMAL
	ABNORMAL FINDINGS
	
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
			
Eyes/ears/nose/throat Pupils equal
Hearing
			
Lymph nodes
			
Heart
Murmurs (auscultation standing, supine, +/- Valsalva)
Location of the point of maximal impulse (PMI)
			
Pulses
Simultaneous femoral and radial pulses
			
Lungs
			
Abdomen
			
Genitourinary (males only)
			
Skin
HSV,lesions suggestive ofMRSA,tinea corporis
			
Neurologic
			
MUSCULOSKELETAL
			
Neck
			
Back
			
Shoulder/arm
			
Elbow/forearm
			
Wrist/hand/fingers
			
Hip/thigh
			
Knee
			
Leg/ankle
			
Foot/toes
			
Functional
Duck walk,single leghop

aConsider ECG,echocardiogram,or referral tocardiology for abnormal cardiac history or exam. bConsider GU examifin privatesetting. Havingthirdpartpresentis recommended.
cConsider cognitiveor baselineneuropsychiatric testingifahistory ofsignificantconcussion.

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 4 of6 CLEARANCE FORM
Note: Authorization forms (pages 5 and 6) must be signed by both the parent/guardian and the student.

Name______________________________________________________________ Sex □ M	□ F	Age____________________ Date ofbirth ________________________________

□ Cleared for allsports without restriction

□ Cleared for allsports without restrictionwith recommendations forfurther evaluation ortreatment for _________________________________________________________ _________________________________________________________________________________________________________________________________________

□ NotCleared
□ Pending further evaluation

□ For any sports

□ For certain sports _____________________________________________________________________________________________________________ Reason _____________________________________________________________________________________________________________________

Recommendations_____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________

I have examined the above-named student andcompleted thepre-participation physical evaluation. The studentdoes not present apparentclinical contraindications topractice andparticipate in the sport(s) as outlined above. A copy ofthe physical examis onrecordinmyoffice andcan be made availableto the school at the request of theparents. In the event that the examinationis conducted enmasse at the school, the school administrator shall retain a copy of the PPE. If conditionsarise after the student has beenclearedfor participation,the physicianmayrescindthe clearanceuntil theproblemis resolved andthe potential consequences are completely explainedto the athlete (and parents/guardians).

Name of physicianor medical examiner (print/type) ___________________________________________________________________ Date ofExam ___________________ Address ______________________________________________________________________________________________ Phone ________________________________

Signature ofphysician/medical examiner ___________________________________________________________________________________, MD, DO, D.C., P.A. orA.N.P.

EMERGENCY INFORMATION

PersonalPhysician _______________________________________________________________________Phone _______________________________________________

In case of Emergency, contact _____________________________________________________________ Phone _______________________________________________

Allergies_____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Other Information _____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 5 of6

THE STUDENT SHALL NOT BE CLEAREDTO PARTICIPATE ININTERSCHOLASTIC ATHLETICS UNTILTHISFORM HAS BEEN SIGNED ANDRETURNED TO THE SCHOOL

OHSAA AUTHORIZATION FORM	2018-2019

I hereby authorizethe releaseand disclosure ofthe personalhealth information of_______________________________ ("Student"),as described below,to ____________________________________ ("School").

The information described below may bereleasedto theSchool principal or assistant principal, athletic director, coach, athletic trainer, physical education teacher, schoolnurse or other member of theSchool's administrativestaffas necessary to evaluate the Student's eligibility toparticipate inschoolsponsored activities, including but notlimited to interscholastic sports programs, physicaleducation classes or otherclassroom activities.

Personal healthinformation oftheStudentwhich may bereleased and disclosed includes records of physicalexaminations performed to determine the Student's eligibility to participatein schoolsponsored activities,includingbut not limitedto the Pre-participation Evaluation form or other similar documentrequired by the School prior todetermining eligibility ofthe Studentto participatein classroom orother Schoolsponsored activities; records of theevaluation, diagnosis and treatmentofinjuries which theStudent incurred while engagingin schoolsponsored activities, including but notlimitedto practicesessions,training andcompetition; and other records as necessary to determine the Student's physicalfitness toparticipate inschoolsponsored activities.

The personal healthinformation described abovemay be released or disclosed totheSchoolby theStudent's personal physician or physicians; a physician orother healthcare professionalretained by theSchoolto perform physicalexaminations to determine theStudent's eligibility to participate incertainschoolsponsored activities orto provide treatment tostudents injuredwhile participating in suchactivities,whetheror not such physicians or other health care professionals are paidfortheirservices or volunteer their timetothe School; or any otherEMT, hospital, physician or other healthcare professionalwho evaluates, diagnoses ortreats an injury or other condition incurred by the student while participating inschoolsponsored activities.

I understandthat theSchool has requestedthis authorizationto release ordisclosethe personal health information described above to make certaindecisions aboutthe Student's healthand ability toparticipate incertainschoolsponsored andclassroomactivities, and that the School is a not a healthcare provider or health plancovered by federal HIPAA privacy regulations, andthe information described below may be redisclosed andmay not continue to be protected by thefederalHIPAA privacy regulations. I also understandthatthe School is covered underthe federal regulations that govern the privacy ofeducational records, and that the personal health information disclosed under this authorization may be protected by those regulations.

I also understandthathealth care providers and healthplans may notcondition theprovision of treatmentor payment on the signing ofthis authorization; however,the Student's participationin certain schoolsponsored activities may be conditioned on the signing ofthis authorization.

I understandthat I may revokethis authorization in writing at any time, except to the extent that action has beentaken bya healthcare provider in reliance on this authorization, by sending a written revocationto the schoolprincipal(or designee) whosename and address appears below.

Name ofPrincipal:

SchoolAddress:

___________________________________________________________

___________________________________________________________

This authorizationwillexpirewhenthestudent is no longer enrolled as astudent at theschool.

NOTE: IFTHESTUDENTISUNDER 18YEARSOFAGE,THISAUTHORIZATION MUSTBESIGNED BYA PARENT OR LEGALGUARDIAN TOBEVALID. IF THE STUDENTIS18 YEARSOFAGE OR OVER, THE STUDENTMUSTSIGN THISAUTHORIZATION PERSONALLY.

________________________________________________________________________________________________________________________________ Student’s Signature	Birth dateof Student, includingyear

_______________________________________________________________________________________________________________________________ Name ofStudent's personal representative, if applicable

I am theStudent's (check one):	_______ Parent _______ Legal Guardian (documentation must be provided)

_______________________________________________________________________________________________________________________________ Signature ofStudent's personal representative,if applicable	Date

A copy of this signedformhas beenprovided tothe studentorhis/her personal representative

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

PREPARTICIPATION PHYSICAL EVALUATION	2018-2019	Page 6 of6 2018-2019OhioHighSchool AthleticAssociation Eligibility andAuthorization Statement

This document isto besignedby theparticipant from anOHSAAmember school andby the participant’sparent.

I haveread, understand and acknowledgereceipt of theOHSAAStudent Athlete EligibilityGuidewhichcontains a summary of the eligibilityrules of the Ohio HighSchool Athletic Association. I understand that a copy of the OHSAAHandbookis onfilewiththe principal andathletic administrator andthat I mayreviewit, initsentirety, if I sochoose. All OHSAAbylaws andregulationsfrom theHandbookarealsopostedonthe OHSAAwebsite at ohsaa.org.

I understand that an OHSAAmember school must adhere toall rules andregulationsthat pertain to the interscholasticathletics programsthat the school sponsors, but that local rules may bemore stringent thanOHSAArules.

I understand that participationininterscholastic athleticsis aprivilege not aright. Student Codeof Responsibility

As astudent athlete, Iunderstandandaccept the following responsibilities:

I will respect therights and beliefs of others andwill treat otherswith courtesy and consideration. I will befully responsiblefor my own actions andthe consequences of my actions.
I will respect thepropertyof others.

I will respect and obeythe rules of my school andlawsof mycommunity, state and country.

I will showrespect tothose whoare responsiblefor enforcingthe rules of my school andthelaws of my community, stateand country.

I understandthat a student whosecharacteror conduct violates the school’s Athletic Code or School Codeof Responsibilityis not in goodstanding andisineligible for aperiod asdetermined bythe principal.

InformedConsent –Byitsnature, participationin interscholastic athleticsincludesrisk of injury andtransmission of infectious diseasesuchas HIV and HepatitisB. Althoughseriousinjuriesarenot common andtherisk of HIVtransmissionis almost nonexistent insupervised school athletic programs, it is impossibleto eliminateall risk. Participantshave aresponsibilitytohelpreducethatrisk. Participantsmust obey all safetyrules, report all physical and hygiene problemstotheir coaches, followa proper conditioning program, andinspect their ownequipment daily. PARENTS, GUARDIANSORSTUDENTS WHOMAYNOTWISH TOACCEPTRISKDESCRIBEDIN THISWARNINGSHOULDNOT SIGN THISFORM. STUDENTSMAYNOTPARTICIPATEIN AN OHSAA-SPONSOREDSPORTWITHOUTTHESTUDENT’SAND PARENT’S/GUARDIAN’S SIGNATURE.

I understand that in the caseof injury or illness requiringtreatment bymedical personnel andtransportationto a healthcarefacility, that a reasonable attempt will bemadetocontact theparent or guardian in thecase of thestudent-athlete being a minor, but that, if necessary, the student-athlete will betreatedandtransported via ambulancetothe nearest hospital.

I consent tomedical treatment for the student following an injuryor illness suffered during practice and/or a contest.

To enabletheOHSAAto determine whether the hereinnamedstudent iseligibletoparticipateininterscholasticathletics inan OHSAAmember school I consent tothe releasetotheOHSAA any andall portions of school recordfiles, beginning with seventh grade, of the herein named student, specifically including, without limitingthegenerality of theforegoing, birthand age records, nameandresidenceaddress of parent(s)or guardian(s), residence address of the student, academicwork completed, gradesreceived and attendance data.

I consent tothe OHSAA’suse of thehereinnamed student’sname, likeness, andathletic-relatedinformationinreportsof contests, promotional literatureof theAssociation andother materials andreleasesrelated tointerscholasticathletics.

I understand that if I dropa class, takecourse workthroughCollege Credit Plus, Credit Flexibility or other educational options, thisaction could affect compliancewithOHSAA academicstandards andmyeligibility.I accept full responsibilityfor compliancewith Bylaw 4-4-1, Scholarship, andthepassingfive credit standardexpressedtherein.

I understandall concussions are potentially seriousand mayresult in complicationsincluding prolongedbraindamageand death if not recognized and managedproperly. Further I understand that if mystudent isremoved from apractice or competition duetoa suspected concussion, heor she will be unable to returnto participationthat day. After that daywrittenauthorizationfrom a physician(M.D. or D.O.) or anathletictrainer working under the supervisionof a physicianwill berequired inorder for the student toreturntoparticipation.

I have read and signedthe Ohio Department of Health’s ConcussionInformationSheet andhave retained acopyfor myself.

By signingthisweacknowledge that we havereadtheabove information andthat weconsent tothehereinnamed student’sparticipation. *Must BeSignedBeforePhysical Examination

_____________________________________________________________________________________________________________________________________________ Student’s Signature	Birthdate	Grade in School	Date

_____________________________________________________________________________________________________________________________________________ Parent’s or Guardian’s Signature	Date

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Collegeof Sports Medicine, American Orthopaedic Society for Sports Medicine,and American Osteopathic Academy of Sports Medicine.Permission is granted to reprintfornoncommercial, educationalpurposes with acknowledgment. -Revised 1/13

Ohio Department of Health Concussion Information Sheet For Interscholastic Athletics
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, lessthan1 out of 10 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 Parentsof Guardians i Appears dazed or stunned.
i Is confused about assignment or position. i Forgets plays.
i Is unsure of game, score or opponent. i Moves clumsily.
i Answers questions slowly.
i Loses consciousness (even briefly).
i Showsbehavior or personality changes(irritability, sadness, nervousness, feeling more emotional).
i Can’t recall events before orafter hit orfall.

Symptoms Reported by Athlete
i Any headache or “pressure”in head. (How badly it hurts does not matter.)
i Nausea or vomiting.
i Balance problems or dizziness. i Double or blurry vision.
i Sensitivity tolight and/or noise
i Feeling sluggish, hazy, foggy orgroggy. i Concentrationor memory problems.
i Confusion.
i Does not “feel right.” i Trouble falling asleep.
i Sleepingmore or lessthan usual.

Be Honest

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 to miss one gamethanthe entire season… or risk permanent damage!

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.

i No athlete should return to activity on the same day he/she gets a concussion.

i Athletes should NEVER return to practices/games if they still have ANY symptoms.

i 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.

hƩp://www.healthy.ohio.gov/vipp/child/returntoplay/concussion

Rev. 09.16

Returning to Daily Activities	Returning to Play

1. Be sure your child gets plenty of rest and enough sleep at night – no late nights. Keep the same bedtime weekdays and weekends.

2. Encourage daytime naps or rest breaks when your child feels tired or worn-out.

3. Limit your child’s activities that require a lot of thinking or concentration (including social activities, homework, video games, texting, computer, driving, jobǦrelated activities, movies, parties). These activities can slow the brain’s recovery.

4. Limit your child’s physical activity, especially those activities where another injury or blow to the head may occur.

5. Have your qualified health care professional check your child’s symptoms at different times to help guide recovery.

1. Returning to play isspecific for each person, depending on the sport.Starting 4/26/13, Ohio law requires written permission from a health care provider before an athlete can return to play. Follow instructions and guidance providedby a health care professional. It is important that you, your child and your child’s coach follow these instructions carefully.

2. 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).

3. Ohio law prohibits your child from returning to a game or practice on the same day he/she was removed.

4. Be sure that the athletic trainer, coach and physical education teacher are aware of your child’s injury and symptoms.

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.

2. Inform teacher(s), school counselor or administrator(s) about the injury and symptoms. School personnel should be instructed to watch for:

5. Your athlete should complete a step-by-step exercise -based progression, under the direction of a qualified healthcare professional.

6. 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.*

a. Increased problems paying attention.

b. Increased problems remembering or learning new information.

c. 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.

3. Be sure your child takes multiple breaks during study time and watch for worsening of symptoms.

4. If your child is still having concussion symptoms, he/ she may need extra help with schoolǦrelated activities. As the symptoms decrease during recovery, the extra help or supports can be removed gradually.

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

Resources

l
ODH Violence and Injury Prevention Program http://www.healthy.ohio.gov/vipp/child/returntopay/

Centers for Disease Control and Prevention http://www.cdc.gov/headsup/basics/index.html

NationalFederationofStateHighSchoolAssociations

www.nfhs.org

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 20Ǧ30 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 sportǦ specific drills without contact or collisions for 30Ǧ45 minutes).

Step 3: Heavy, nonǦcontact 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 nonǦcontact sports specific drills, agility training and jumping drills for 45Ǧ60 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.

Brain Injury Association of America www.biausa.org/

hƩp://www.healthy.ohio.gov/vipp/child/returntoplay/concussion

Rev. 09.16

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

Rev. 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

What is SCA? SCA is when the heart stops beating suddenly and unexpectedly. This cuts off blood ﬂow to the brain and other vital organs. People with SCA will die if not treated immediately. SCA can be caused by 1) a structural issue with the heart, OR 2) an heart electrical problem which controls the heartbeat, OR 3) 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.

_____________________________________ Parent/Guardian Signature

______________________________________ Parent/Guardian Name (Print)

______________________________________ Date

Department of Health

___________________________________ Student Signature

____________________________________ Student Name (Print)

_______________________________________ Date

Department of Education