Sample Recommended NYSED Interval Health History for Athletics Page 2 – Student Name: School Name: DOB: Has/Does your child: Heart Health Yes No 32. Ever passed out during or after exercise? 33. Ever complained of light headedness or 34. dizziness Ever complained during or of after chest exercise? pain, tightness or pressure during or after exercise? 35. Ever complained of fluttering in their chest, skipped beats, or their heart racing, or does he/she have a pacemaker? 36. Ever had a test by medical provider for his/her heart (e.g. EKG, echocardiogram stress test)? 37. Ever been told they have a heart condition or problem by a physician? If so, check all that apply: infection Murmur ☐Heart ☐Heart Pressure Blood Pressure ☐High ☐Low Cholesterol Disease ☐High ☐Kawasaki ☐Other: Injury History Yes No 38. Ever been diagnosed with a stress fracture? Please explain fully any question you answered yes to in the space below. (Please print clearly and provide dates if known. Date: Parent/Guardian Signature:
Sample Recommended NYSED Interval Health History for Athletics – Page 2 Student Name: School Name: DOB: Has/Does your child: Heart Health Yes No 32. Ever passed out during or after exercise? 33. Ever complained of light headedness or dizziness during or after exercise? 34. Ever complained of chest pain, tightness or pressure during or after exercise? 35. Ever complained of fluttering in their chest, skipped beats, or their heart racing, or does he/she have a pacemaker? 36. Ever had a test by medical provider for his/her heart (e.g. EKG, echocardiogram stress test)? 37. Ever been told they have a heart condition or problem by a physician? If so, check all that apply: ☐Heart infection ☐Heart Murmur ☐High Pressure ☐Low Blood Pressure ☐High Cholesterol ☐Kawasaki Disease ☐Other: Injury History Yes No 38. Ever been diagnosed with a stress fracture? Please explain fully any question you answered yes to in the space below. (Please print clearly and provide dates if known. Parent/Guardian Signature: Date:
IntervalHealthHxforExam_Athletics.docx