Secondary Medical Forms - Phillipsburg School District

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NOTES TO THE EXAMINING PROVIDER Conditions requiring clearance before sports participation include, but are not limited to the following: Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye. SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT Contact/Collision Limited Contact Non-Contact Strenuous Non-strenuous Basketball Baseball Discus Bowling Diving Cheerleading Javelin Golf Field Hockey Fencing Shot put Football High Jump Rowing Ice Hockey Pole vault Running/Cross Country Lacrosse Gymnastics Strength Training Soccer Skiing Swimming Wrestling Softball Tennis Volleyball Track N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the student’s school health record. Effects of physiologic maneuvers on heart sounds: Physical Stigmata of Marfan’s Syndrome Standing Increases murmur of HCM Kyphosis Decreases murmur of AS, MR High arched palate MVP click occurs earlier in systole Pectus excavatum Arachnodactyly Squatting Increases murmur of AS, MR, AI Arm span > height 1.05:1 or greater Decreases murmur of MCH Mitral Valve Prolapse MVP click delayed Aortic Insufficiency Myopia Valsalva Increases murmur of HCM Lenticular dislocation Decreases murmur of AS, MR MVP click occurs earlier in systole HCM = Hypertrophic Cardio Myopathy AS = Aortic Stenosis AI = Aortic Insufficiency MR = Mitral Regugitation MVP = Mitral Valve Prolapse Part B Page 4 of 4 NJDOE/APPEF 10/07 Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development
Phillipsburg School District 445 Marshall Street Phillipsburg, New Jersey 08865 PHILLIPSBURG HIGH SCHOOL ATHLETICS 200 HILLCREST BLVD. PHILLIPSBURG, NJ 08865 908-213-2493 Dear Parents/Guardians, Prior to participation in a school sport, students must provide the following information to the school nurse or trainer by the due dates below: • A current physical exam must be completed within 365 days prior to the first practice of the sport. • A parent permission and health history questionnaire must be completed within 60 days of the start of each new sport season to advise of any medical problems experienced since the last medical exam. • The above information must be reviewed and approved by the school medical examiner. Fall season physicals and permission forms are due to the health office by August 3rd. Fall sports practices may begin as early as August 17 th . Winter season physicals and permission forms are due to the health office by November 4 th . Swimming practice starts November 9 th all other sports begin November 27 th . Spring sport physicals and permission forms are due to the health office by February 19 th . All spring sport practices start March 5th. Physical exams and permission forms turned in after the due date may result in missed practices and tryouts. PHYSICALS FORMS ARE LOCATED ON THE PHILLPSBURG HIGH SCHOOL WEB PAGE: www.pburgsd.net Go to the Athletic Site and click on PHS Physical Forms Packet. Forms are also available in the High School Athletic Office and Main Office. Revised 3 09
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Page 11 and 12: ANNUAL ATHLETIC PRE-PARTICIPATION P
Page 13: CLEARANCES: (See notes at bottom fo

Secondary Medical Forms - Phillipsburg School District

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