<Photo of Tigers> Fayette County High School Band
 
Fayetteville, Georgia
Myra Rhoden, Director
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Elizabeth DavidsonElizabeth Davidson
    

WORLD EVENTS
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  • LaFayette Marching
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  • Special LMC Update
  • The FCHS Band is London Bound
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  • Winter Guarder

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    Exam Date:                              Annual Participation Health Screening                School:  Fayette County HS            The undersigned represents that he/she is the parent/legal guardian of the student named below and hereby authorizes the state required extra-curricular health screening. (This evaluation is a screening NOT a diagnostic and/or treatment session). We hereby state that, to the best of our knowledge, the answers to the questions below are complete and correct.
    Student Signature: _________________________     Parent/Guardian Signature:________________________
    Date: ________________                                                  Date: ________________

    Personal Information (print clearly)    Current School: Fayette County High        
    Student's Name: ___________________________ Sex: M ___   F ___   Age: ____ Date of Birth: ___________
    Home Address: ______________________________ City: ________________________, GA  Zip:________
    Emergency Contact: _____________________________ Home Phone: (_____)________________
    Work Phone: (_____) _________________
    Personal Physician: ______________________ Address: ___________________ Phone: (____) __________

    Medical History Of Student  Explain YES answers below.   Circle any questions you do not know the answer.

    1. Have you had a medical illness / injury since last check up / screening?  Y  N 28. Do you have a hernia / hernia related problems?  Y  N
    2. Have you been hospitalized overnight?  Y  N 29. Do you use any special equipent? (i.e. knee brace, special nec roll, mouth / eye piece)  Y  N
    3. Have you had surgery?  Y  N 30. Have you had a sprain, strain, or swelling after an injury?  Y  N
    4. Are you currently taking any prescription or non-prescription medications / pills or inhaler?  Y  N 31. Have you broken, fractured any bones or dislocated any joints?  Y  N
    5. Have you taken supplements / vitamins to help you gain / lose weight to improve your performance?  Y  N 32. Have you ever had other problems with pain or swelling in muscles / tendons / bones / joints?  If yes, mark below and explain.  Y  N
    6. Do you have any allergies *foods, pollen, medications, insects?)  Y  N . Head     Neck     Back     Chest     Ankle     Elbow    
    7. Do you get tired more easily than others during exercise?  Y  N   Wrist   Forearm    Hand    Foot  Hip  Thigh   Knee    
    8. Have you had high blood pressure or high cholesterol?  Y  N   Finger    Shin      Shoulder     Upper Arm      Calf    
    9. Have you had racing of your heart or skipped heartbeats?  Y  N 33. Do you want to weigh more / less than you do now?  Y  N
    10. Have you ever passed out during exercise?  Y  N 34. Do you lose weight regularly to meet requirements for you activity?  Y  N
    11. Have you ever been told you have a heart murmur?  Y  N 35. Do you feel stressed out?  Y  N
    12. Have you ever been dizzy after exercise?  Y  N        
    13. Have you ever had chest pain during / after exercise?  Y  N   For Female Participants Only    
    14. Has any family member / relative died of heart problems or sudden death before age 50?  Y  N 1. When was your last menstrual cycle?
    Date:
    15. Have you ever been told you have Marfan's Syndrome (heart condition)?  Y  N 2. When was your most recent menstrual cycle? Date:    
    16. Have you had a severe viral infection (i.e. Myocarditis / Mononucleosis) in the last year?  Y  N 3. What is the normal time frame between periods?
    # Days    		    
    17. Has a physician denied / restricted your participation in sports for any heart problem?  Y  N 4. How many periods have you had in the last year?    
    18. Do you have frequent or severe headaches?  Y  N 5. What was the longest time between periods last year?  # Days    
    19. Have you had a head injury/concussion?  Y  N        
    20. Have you ever had a seizure?  Y  N   Explain all YES answers here.  Write question # and brief description below:    
    21. Have you ever been knocked out, become unconscious, or lost your memory?  Y  N        
    22. Do you have any current skin problems? (i.e. rashes, itching, acne, warts, blisters)  Y  N        
    23. Have you had numbness / tingling in your arms / legs / feet?  Y  N        
    24. Have you become ill from exercising in the heat?  Y  N        
    25. Do you have seasonal allergies that require medical treatment?  Y  N        
    26. Do you cough, wheeze, or have trouble breathing during / after exercise?  Y  N        
    27. Do you have asthma?  Y  N Participating Activity:  Marching Band
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