Parent Portal

North East ISD - Athletics

Instructions

PARENT LOGIN

Student First Name: * Required

Student Last Name: * Required

Date of Birth: * *Invalid Date Required

Student ID: * Required

School Attending in 2024 - 2025: * Required

Medical History (Middle School)

North East ISD - Athletics 2024/2025

Please ONLY enter Date of birth and Student ID, without the leading zero. First Name, Last Name, and Campus will auto-fill when student record is found

For Student ID Above: Do not use leading Zero

This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.

Student Full Name*Required

Gender*Required

Age*Required

DOB

*Invalid Date

Grade*Required

Student ID #

Address*Required

Phone*Required

School*Required

Personal Physician*Required

Phone*Required

Emergency Contact Name:*Required

Relationship:*Required

Phone: (Home)*Required

Phone: (Work)*Required

Parent Email

Any Yes answer to questions 1-22 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE, PERFORMANCE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.

1. Have you had a medical illness or injury since your last check up or sports physical?YesNo*Required

Explain*Required

2. Have you been hospitalized overnight in the past year?YesNo*Required

Explain*Required

3. Have you ever had surgery?YesNo*Required

Explain*Required

4. Have you ever had prior testing of the heart ordered by a physician?YesNo*Required

Explain*Required

5. Have you ever passed out during or after exercise?YesNo*Required

Explain*Required

6. Have you ever had chest pain during or after exercise?YesNo*Required

Explain*Required

7. Do you get tired more quickly than your friends do during exercise?YesNo*Required

Explain*Required

8. Have you ever had racing of your heart or skipped heartbeats?YesNo*Required

Explain*Required

9. Have you had high blood pressure or high cholesterol?YesNo*Required

Explain*Required

10. Have you ever been told you have a heart murmur?YesNo*Required

Explain*Required

11. Has any family member or relative died of heart problems or of sudden unexpected death before age 50?YesNo*Required

Explain*Required

12. Has any family member been diagnosed with enlarged heart, (dilated cardiomyopathy), hypertrophic cardiomyopathy, long QT syndrome or other ion channelpathy (Brugada syndrome, etc), Marfan's syndrome, or abnormal heart rhythm?

YesNo*Required

Explain*Required

13. Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month?YesNo*Required

Explain*Required

14. Has a physician ever denied or restricted your participation in sports for any heart problems?YesNo*Required

Explain*Required

15. Have you ever had a head injury or concussion?YesNo*Required

How Many Times? When was last one? How severe was each one?*Required

16. Have you ever been knocked out, become unconscious, or lost your memory?YesNo*Required

Explain: If yes, how many times? & When was the last concussion? & How severe was each one?*Required

17. Have you ever had a seizure?YesNo*Required

Explain*Required

18. Do you have frequent or severe headaches?YesNo*Required

Explain*Required

19. Have you ever had numbness or tingling in your arms, hands, legs, or feet?YesNo*Required

Explain*Required

20. Have you ever had a stinger, burner, or pinched nerve?YesNo*Required

Explain*Required

21. Are you missing any paired organs?YesNo*Required

Explain*Required

22. Are you under a doctor’s care?YesNo*Required

Explain*Required

23. Are you currently taking any prescription or non-prescription (over-the-counter) medication or pills or using an inhaler?YesNo*Required

Explain*Required

24. Do you have any allergies (for example, to pollen, medicine, food, or stinging insects)?YesNo*Required

Explain*Required

25. Have you ever been dizzy during or after exercise?YesNo*Required

Explain*Required

26. Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, or blisters)?YesNo*Required

Explain*Required

27. Have you ever become ill from exercising in the heat?YesNo*Required

Explain*Required

28. Have you had any problems with your eyes or vision?YesNo*Required

Explain*Required

29. Have you ever gotten unexpectedly short of breath with exercise?YesNo*Required

Explain*Required

30. Do you have asthma?YesNo*Required

Explain*Required

31. Do you have seasonal allergies that require medical treatment?YesNo*Required

Explain*Required

32. Do you use any special protective or corrective equipment or devices that aren't usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)?

YesNo*Required

Explain*Required

33. Have you ever had a sprain, strain, or swelling after injury?YesNo*Required

Explain*Required

34. Have you broken or fractured any bones or dislocated any joints?YesNo*Required

Explain*Required

35. Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints?YesNo*Required

Explain & If yes, check appropriate box and explain below.*Required

Head

Neck

Back

Chest

Shoulder

Upper Arm

Elbow

Hand

Finger

Hip

Thigh

Knee

Shin/Calf

Ankle

Foot

Foream

Wrist

36. Do you want to weigh more or less than you do now?YesNo*Required

Explain*Required

37. Do you feel stressed out?YesNo*Required

Explain*Required

38. Have you ever been diagnosed with or treated for sickle cell trait or sickle cell disease?YesNo*Required

Explain*Required

Female Questions "If Female, Check Yes"YesNo*Required

39. When was your first menstrual period?*Required

40. When was your most recent menstrual period?*Required

41. How much time do you usually have from the start of one period to the start of another?*Required

42. How many periods have you had in the last year?*Required

43. What was the longest time between periods in the last year?*Required

Male Questions "If Male, Check Yes"YesNo*Required

44) Do you have two testicles?YesNo*Required

Explain*Required

45) Do you have any testicular swelling or masses?YesNoN/A*Required

Explain*Required

An electrocardiogram (ECG) is NOT required.I have read and understand the information about cardiac screening on the UIL Sudden Cardiac Arrest Awareness Form. By checking this box, I choose to obtain an ECG for my student for additional cardiac screening. I understand it is the responsibility of my family to schedule and pay for such ECG.

YesNo*Required

• It is understood that even though protective equipment is worn by athletes, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any responsibility in case an accident occurs.
• If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.
• If, between this date and the beginning of participation, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury.

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL

Parent/Guardian Name (print):*Required

Signature of Parent/Guardian

Date

*Invalid Date

Student Name (Print)*Required

Student Signature

Date

*Invalid Date

Pursuant to the Texas Uniform Electronic Transmissions Act, an electronic signature has the same legal effect as a manual or handwritten signature. An electronic signature will not be denied legal effect or enforceability solely because it is electronic, and any requirement for a signature is satisfied by an electronic signature. By submitting an electronic signature, the individual identified and providing the electronic signature herein verifies acknowledgement of the binding legal effect and enforceability of the electronic signature. By clicking the box beside "I agree", you agree that this is valid as your signature. You hereby swear that you are the above named student OR parent or legal guardianand that the information is accurate to the best of your knowledge.

*Required

We Agree

Notification Email: Parent Email: *Required If the student is 18 and completing the form themselves, please enter their email. If the student is under 18 or the parent/guardian is completing the form, please enter the parent/guardian email. An email notification will be sent once the form has been approved.

The following information will be sent to NCSA: Athlete Name, Athlete Phone, Athlete Email, Athlete Zip Code, Graduation Year, Preferred Sport, Guardian Name, Guardian Phone, Guardian Email

Rank One has partnered with NCSA College Recruiting to offer access to college recruiters.

Does your child hope to compete in sports at the college level? YesNo

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