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
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