Tri-west marching blue alliance health form 2009

TRI-WEST MBA HEALTH FORM

_________________ _____ _______________ __________________
Student Name Grade Section/Guard Date
Please list any allergies to medicines, foods, latex, and insect stings on the above line
Welcome to a new season of the Tri-West Marching Blue Alliance! Marching band is
a very strenuous activity. Please answer the following questions with your child/student.
We need all health forms by the start of competition. These forms will be kept in staff
possession during the season and treated as confidential health information for
emergency use only.
PLEASE EXPLAIN ANY “YES” ANSWERS TO THE FOLLOWING QUESTIONS:
Have you (student) ever been hospitalized or had surgery?-------------------------Y N
Are you presently under a doctor’s care?----------------------------------------------Y N
Are you taking any medication?---------------------------------------------------------Y N
Are you allergic to any medications or bees/insects?---------------------------------Y N
Have you ever fainted or passed out after exercise?----------------------------------Y N
Have you ever had chest pain during or after exercise?------------------------------Y N
Have you ever had high blood pressure?-----------------------------------------------Y N
Have you ever been told you had a heart murmur?-----------------------------------Y N
Have you ever had racing of your heart or skipped beats?---------------------------Y N
Has anyone in your family died of a heart problems?--------------------------------Y N
Has anyone had a sudden death before age of 50?------------------------------------Y N
Has anyone in your family had the connective tissue disorder called Marfan Syndrome?
-----------------------------------------------------------------------------------------------Y N
Do you have asthma, asthma attacks with exercise, or use inhalers?--------------Y N
Do you have trouble breathing or cough after strenuous exercise?-----------------Y N
Are you diabetic, if yes do you take insulin?-------------------------------------------Y N

Have you sprained, dislocated, fractured, or had swelling of bones or joints? (Please
circle all that apply.)
Head Shoulder Thigh Neck Elbow Knee Foot Forearm Shin/Calf Wrist
Back Hip Ankle Hand
Have you had any other medical problems or injuries since last year? (Diabetes, Mono,
Anemia, etc.)---------------------------------------------------------------------------Y N
When was your last Tetanus Shot? (Should be within last 10 years)______________
Please explain any yes answers here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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I give my student permission to participate with the Marching Blue Alliance. I also give
the Tri-West Band Staff permission to give consent for emergency treatment of my child
in the event that I cannot be present or be reached in an emergency. Please circle any of
the following meds that we may give your student: Tylenol, Ibuprofen, and Benadryl
Signature of Parent/Guardian Date
IMPORTANT NOTE: If your child uses an inhaler for asthma or exercise induced
asthma, they must have it in their possession at all times (or in their case on the
sideline) throughout Band Camp, all Practices, and at Competitions!!
If your student’s insect or food allergy is severe enough to require an epipen injector, as
determined by your physician, please make sure your student HAS TWO injectors either
on their person or in the med kit at the sideline at ALL practices and competitions.
Any other special medical requirements or medications needs to be further discussed with
Mark Frederick.

Source: http://twhs-band-boosters.twhs.hendricks.k12.in.us/modules/groups/homepagefiles/gwp/1602104/2155602/File/health%20form.pdf?sessionid=cc3157e8edf8914e549ef59e6f7ba927