IREDELL COUNTY YOUNG ATHLETE’S ASSOCIATION
ATHLETIC MEDICAL EXAMINATION FORM
(ICYAA)
MEDICAL EXAMINATION FOR:
Name:________________________________________
Height___________Weight_________Blood Pressure_________Date of Physical_______________
NORMAL ABNORMAL DESCRIBE ABNORMALITIES
1.__________ Eyes ___________ ____________________________________
2.__________ ENT ___________ _____________________________________
3.__________ Heart ___________ ____________________________________
4.__________ Lungs _________ ______________________________________
5.__________ Abdomen __________ _____________________________________
6.__________ Genitalia ___________ _______________________________________
(males only) ________
7.__________ Musculoskeletal ___________ __________________________________
8.__________ Neurological ___________ ____________________________________
9.__________ Skin ___________ _____________________________________
LABORATORY
Urinalysis (Optional):
________________________________________________________________________________
Other (where indicated):
______________________________________________________________________________
I certify that I have examined this student and find him/her medically (qualified/not qualified) to
compete in athletics.
Signature_____________________________________ Date of Examination ____________________
Licensed to practice in N. C. ? ______Yes ______No
If student is not qualified, list the reason(s) for disqualification: _____________________________
_____________________________________________________________________________________
(The following are considered disqualifying until medical and parental releases are obtained: acute
infections, obvious growth retardation, diabetes, jaundice, severe visual or auditory impairment,
pulmonary insufficiency, organic heart disease or hypertension, enlarged liver or spleen, hernia,
musculoskeletal deformity associated with functional loss, history of convulsions or concussions,
absence of one kidney, eye or testicle.)
MEDICAL HISTORY
(to be completed by parents prior to medical examination)
Student_____________________________________________________ Date of Birth____________
Is there a known history of:
Birth deformities (one eye, one kidney, etc.)? _____Yes _____No
Known past illness of more than one week’s duration? _____Yes _____No
Medical conditions currently under treatment? _____Yes _____No
Fractures or other disabling injuries? _____Yes _____No
Any permanent deformity or disability? _____Yes _____No
Allergies (drugs, food, clothing, etc.)? _____Yes _____No
Mental disorder or convulsions? _____Yes _____No
Asthma? _____Yes _____No
Currently taking any medications? _____Yes _____No
Explain any above questions answered “Yes”:________________________________________
___________________________________________________________________________________
Protect Your Eligibility by Knowing the Rules. To Participate in Athletics, You:
· Must be a properly enrolled student in the school at which you participate
· Must have been in attendance for at least 85% of the previous semester
· Must be under 12 years of age on October 15th of current school year
· Must live with your parents or person who has legal custody in the school district where you
are participating.
· Must have passed at least one less course than the number of required core courses during
the previous semester, and meet local promotion and attendance standards
· You and your parents must attend the required pre-season meeting with the coach
· Must have a medical examination each year
· Upon entering the seventh grade, students have four consecutive semesters to participate in
middle school athletics beginning with the 2006-07 school year.