The NDHSAA has come out with a Form B which is a physical wavier form. Because of COVID-19, the NDHSAA didn't want to over run the clinics with students getting physicals, so they are now waiving the physical for the 2020-21 season IF a student had a physical in 2019-20. I've attached Form B here. 
 
In talking with the clinics, they didn't feel that they are over run with patients and that it wouldn't be a problem to give physicals to the students. If parents choose to go this route, I've attached the new physical form. In talking with Mike Callahan, our Essentia Sports Medicine Trainer, we think it would be good if our students still took the physical. However, we don't want to mandate this, so I've provided the physical sheet that was new this past fall. All students who didn't have a physical last year, including incoming 7th graders, will need to take a physical and have page 5 turned in. 
 
Finally, we are going to move to online sign-up and form submission through School sometime in July. Our hope is that it will help streamline the process of signing up for activities and submitting of the various forms that you need for activities. More information will be coming as we go online. 
 
Students will not need a physical form B or page 5 of the physical form turned in prior to participating in the summer workouts that we have starting on Monday, June 8th.
 
 
 

NDHSAA 2020-21 ANNUAL SPORTS HEALTH QUESTIONNAIRE – FORM B
This is a fillable Word Document. Use TAB to move through information boxes. Fields will expand as you type.

DATE (mm/dd/yyyy) / / Name Age Birth Date (mm/dd/yyyy) //

Grade (7-12) School Sport(s)

Address

Phone Date of Last Sports Qualifying Physical Exam (SQPE) (mm/dd/yyyy) / /



Check Yes or No boxes for each question or Circle question numbers for which you cannot answer.



IN THE LAST YEAR, since your last complete Sports Qualifying Exam with your physician, HAVE YOU HAD ANY CHANGES TO THE FOLLOWING QUESTIONS:

 

Athlete Health Questionnaire

Over the past 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)

Not at all Several days Over half the days Nearly every day

Feeling nervous, anxious, or on edge             0 1 2 3
Not being able to stop or control worrying       0 1 2 3
Little interest or pleasure in doing things         0 1 2 3
Feeling down, depressed, or hopeless            0 1 2 3

(If the sum of responses to questions             1 & 2 or 3 & 4 are ≥3, please see your provider) YES NO



  1. In the last year, has a doctor restricted your participation in sports for any reason without clearing you to return to sports?

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOU IN THE LAST YEAR

  1. In the last year, have you passed out or nearly passed out during or after exercise?

  2. In the last year, have you had discomfort, pain, tightness, or pressure in your chest during exercise?

  • In the last year, does your heart race or skip beats (irregular beats) during exercise?

  • In the last year, do you get light-headed or feel more short of breath than expected during exercise?

  • In the last year, have you had an unexplained seizure?

IMPORTANT HEART HEALTH QUESTIONS ABOUT YOUR FAMILY IN THE LAST YEAR

  1. In the last year, has anyone in your immediate family died suddenly and unexpectedly for no apparent reason?

  2. In the last year, has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before

age 35 (including an unexplained drowning or an unexplained car accident)?

  1. In the last year, has anyone in your immediate family had instances of unexplained fainting, seizures, or near drowning?

  2. In the last year, has anyone in your immediate family been diagnosed with hypertrophic cardiomyopathy, Marfan Syndrome,

arrhythmogenic right ventricular cardiomyopathy, long or short QT Syndrome, Brugada Syndrome, or catecholaminergic polymorphic

ventricular tachycardia?

  1. In the last year, has anyone in your immediate family under age 35 had a heart problem, pacemaker, or implanted defibrillator?

MEDICAL RISK QUESTIONS IN THE LAST YEAR

  1. In the last year, have you had a head injury or concussion that still has symptoms like continuing headaches, concentration problems

or memory problems

 

Parents or Legal Guardians: Please note below any health concerns, medications, or allergies that may be important
for the coaches or athletic/activities director to know.
(Field will expand as you type)

 

 

I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above questions are true and accurate and I approve participation in athletic activities.

/ /

Parent or Legal Guardian Signature Athlete Signature Date

 

Activities Director Notes:

a YES answer to any of the questions above requires a clearance note from a physician prior to participation.

 

 

 

SQPE Due ____ / _____ /________ CLEARED FOR SPORTS: YES NO

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