Nedrose Student Athlete Sports Physical Registration
Sports physicals provided by Minot Health Clinic on April 27, 2026, at Nedrose High School, from 8:00 AM–12:00 PM and 12:30 PM–2:30 PM. Cost is $50 and is due at registration. Please select an appointment time below and complete the NDSAA History Form. You do NOT need to bring a hard copy of the sports physical paperwork to your appointment.
Appointment
Email
*
example@example.com
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NDHSAA PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
Name (First & Last):
*
Date of birth:
*
-
Month
-
Day
Year
Date
Date of examination (Please Enter 04/27/2026)
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Month
-
Day
Year
Date
Sport(s)
*
Sex
*
Age
*
Grade
*
School
*
List past and current medical conditions.
Have you ever had surgery? If yes, list all past surgical procedures.
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Place an X in the box.)
Rows
Not at all
Several days
Over half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
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GENERAL QUESTIONS
Explain "Yes" answers at the end of this form.
1. Do you have any concerns that you would like to discuss with your provider?
*
Yes
No
2. Has a provider ever denied or restricted your participation in sports for any reason?
*
Yes
No
3. Do you have any ongoing medical issues or recent illness?
*
Yes
No
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HEART HEALTH QUESTIONS ABOUT YOU
4. Have you ever passed out or nearly passed out during or after exercise?
*
Yes
No
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
*
Yes
No
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
*
Yes
No
7. Has a doctor ever told you that you have any heart problems?
*
Yes
No
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
*
Yes
No
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
*
Yes
No
10. Have you ever had a seizure?
*
Yes
No
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?
*
Yes
No
12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly- morphic ventricular tachycardia (CPVT)?
*
Yes
No
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?
*
Yes
No
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BONE AND JOINT QUESTIONS
14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?
*
Yes
No
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?
*
Yes
No
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MEDICAL QUESTIONS
16. Do you cough, wheeze, or have difficulty breathing during or after exercise?
*
Yes
No
17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
*
Yes
No
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
*
Yes
No
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
*
Yes
No
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
*
Yes
No
21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
*
Yes
No
22. Have you ever become ill while exercising in the heat?
*
Yes
No
23. Do you or does someone in your family have sickle cell trait or disease?
*
Yes
No
24. Have you ever had, or do you have any problems with your eyes or vision?
*
Yes
No
25. Do you worry about your weight?
*
Yes
No
26. Are you trying to or has anyone recommended that you gain or lose weight?
*
Yes
No
27. Are you on a special diet or do you avoid certain types of foods or food groups?
*
Yes
No
28. Have you ever had an eating disorder?
*
Yes
No
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FEMALES ONLY
29. Have you ever had a menstrual period?
Yes
No
30. How old were you when you had your first menstrual period?
32. How many periods have you had in the past 12 months?
31. When was your most recent menstrual period?
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Explain "Yes" answers here.
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signature of athlete:
*
Signature of parent or guardian:
*
Date:
*
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Month
-
Day
Year
Date
Name:
Date of birth:
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Month
-
Day
Year
Date
Name:
Date of birth:
-
Month
-
Day
Year
Date
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SHARED EMERGENCY INFORMATION
Allergies:
Medications:
Other Information:
Emergency Contacts (Name and phone number):
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PERMISSION FOR MEDICAL TREATMENT
In the event of an emergency requiring medical attention, I hereby grant permission for emergency treatment for my daughter/son. I expect an effort will be made to contact me if an emergency occurs. I understand the cost for any medical attention may not be covered or paid by any high school or the North Dakota High School Activities Association. I hereby approve participation in athletic activities.
Grade of Athlete
School
Sport(s)
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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Sports Physical
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