CHAPPAQUA CENTRAL SCHOOL DISTRICT

66 Roaring Brook Road Chappaqua, NY 10514

Chappaqua Central Covid-19 Return to Athletics - Health Care Provider Form Dear parent/guardian and healthcare provider,

This form should be brought to your visit and completed by the Health Care Provider. It is required for all student-athletes who have tested positive for COVID-19 and/or have a history of COVID-19 infection. These individuals have already completed the required isolation period or have been released from isolation per DOH guidelines to return to school.

To the healthcare provider: Please complete this medical clearance form for participation in athletics.

Student’s Name: ___________________________ DOB: __________________________

Date of Positive COVID-19 Test: __________________ Date of HCP Eval: _____________ Category of Positive COVID-19 Diagnosis (Check One):
_____ Asymptomatic or Mild Symptoms
_____ Moderate Symptoms

_____Severe Symptoms

Criteria to begin activities (to be completed by Health Care Provider):

Please circle YES or NO. Any YES responses may require further evaluation.

• ●  Hospitalization due to COVID symptoms YES NO

• ●  History of cardiac abnormalities followed by cardiologist YES NO

• ●  RECENT SYMPTOMS:

  • ○  Chest pain at rest or w/ exertion? (not musculoskeletal or costochondritis YES NO

  • ○  Shortness of breath w/ minimal activity? YES NO

  • ○  Excessive fatigue w/ exertion? YES NO

  • ○  Abnormal heartbeat or palpitations? YES NO

  • ○  Syncope or near-syncope? YES NO

• ●  Current normal cardiovascular exam? YES NO

  Healthcare Provider must answer the following questions:

  Does this student need further cardiology assessment? YES NO Is this student cleared for full participation in activities? YES NO

  Provider Name:____________________________Provider Stamp:_____________________ Provider Signature:___________________________________________
  
  Link to this form: COVID Return to Athletics