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WILDCAT PRESS
!
November 2015/Issue III
Mrs. Karla Darnall, Superintendent/Principal
! Ms. Alyse Eckenrode, Associate Principal
www.pacificunionschool.org
Board Members: Jason Barr, Karan Collenberg, Chris Emmons, Dirk Luoma, Ted Weller
Absences
If your child is absent, please
contact the school office at
822-4619. Three or more
unexcused absences may result in
a truancy notice. Please help your
child be at school by 8:25.
Students who are punctual are
creating GOOD WORK HABITS
FOR THEIR FUTURE. Please
contact your child’s teacher and
office staff prior to any PLANNED
ABSENCES, at least three to five
school days in advance. If you
have any questions, please call
Barb Hooper in the office.
Dress Code
Our Code of Conduct addresses the
responsibility of appropriate dress.
Students inappropriately dressed will
call home for proper attire.
•!
•!
•!
•!
•!
•!
•!
•!
•!
•!
No shorts/skirts that
do not meet the ends
of the fingertips with
rested arms at the
side.
No spaghetti strap
shirts/dresses.
No bare midriffs or
revealing cleavage.
No pants worn below
waste/hip area.
No undergarments
showing.
No pajamas (except
for Pajama Day.)
No backless shoes/
sandals, flip-flops or
slippers (safety
issue).
No shoes with
wheels.
No hats indoors hats worn outside are
to be worn properly
(not backward or
halfway on the head.)
No bandanas.
International Walk to School Day!
Over 150 Pacific Union School students participated in the
International Walk to School Day! Mr. Stackhouse (pictured
above), Mr. Huschle, Ms. Watson, Mrs. Navarre and Ms.
Pelafigue met in different locations within our school district to
walk with their group of students. What a FUN way to get to
school! $
Coming Up….!
November 1 - Pacific Standard Time (Fall BACK 1 hour)$
November 11 - Veterans Day (NO SCHOOL)$
November 20 - End of 1st Trimester$
November 23-27 - Thanksgiving Break (NO SCHOOL)$
December 7-11 - Parent/Teacher Conferences (Early dismissal@1:35)$
1
November 2015/Issue III
Pastels on the Plaza!
!
Several Pacific Union
School students gathered
at the Arcata Plaza on
October 3rd to
demonstrate their
artistic abilities - WOW!
What a spectacular piece
of art!!! Too bad it’s not
permanent!!!
Masterpiece in the making!
Fiona Kingery & Sam Crivelli
The MASTERPIECE!
The 2015 $
Pastels on the Plaza
was the BEST EVER!
Sam Crivelli & Kiersten Dotson,
from Pacific Union’s Daycare,
show their leadership skills as
they guide our young artists in
this year’s
!
MASTERPIECE! $
You make us proud!!!
2
October FUN!
Top: 8th grade volleyball team huddling before a game;
8th grade volleyball team and our friendly Wildcat mascot!
Middle: October’s Munch-A-Lunch students;
Mrs. Holm waiting to serve at the staff -vs- 8th grade volley
ball match!
Bottom: Nick Croinex and Wohali’ Bishop (yard supervisors)
pose for Red Ribbon Week “Twin Day”!
Pacific Union School District
Community Fund
A fund at Humboldt Area Foundation (HAF) is established to promote and enhance the quality
of education in the Pacific Union District by supporting education projects. Gifts may be made
to honor individuals or in memoriam. The names of the remembered will be listed in the
memorial section of the HAF.
Gifts can be made out to:
Pacific Union School District Community Fund
Please mail to:
HAF
373 Indianola Rd.
Bayside, CA 95524
Birthday Treats
Please check with your
child’s teacher before
bringing birthday treats.
Classes are allowed to
have sweets one time
per month.
Thanks for your support!
NOT allowed at school:
Pokemon Cards
Dungeon & Dragons Cards
Magic Cards
Glass%containers,%soda,%high1
energy%drinks,%or%specialty%
drinks%are%NOT%allowed%at%
school.%THANK%YOU!%
Get your YEARBOOK…. NOW!
Every year we have SEVERAL students who don’t buy their yearbooks and are SAD at
the end of the school year because they don’t have that special memory.
Don’t be one of the SAD people – ORDER TODAY (order form is attached.)
2015 – 2016
Our yearbook is planned to include:
• All color pages that vibrantly capture school memories.
• Durable, high-quality hard cover protects treasured memories
for a lifetime.
Yearbook Pricing
Hard Cover Yearbook - $25.00
Soft Cover Yearbook - $20.00
Please attach a check or enclose cash in an envelope and return to
school office prior to April 1, 2016.
STUDENT NAME: _____________________________ GRADE: ___________
TEACHER NAME/HOMEROOM: _____________________________________
Thank you for your Yearbook Order!!!
For office use only
Cash
Check
Amount
Riley, Brenden & Sarah Mosher enjoy pizza time!
Mrs. Davies-Hughes, Ms. Florian, Mrs. Pierce, and Ms.
Villanueva serve it up FAMILY style!
Pacific Union’s
Family Reading
Night 2015
Malorie & Zoe McCurdy enjoying a reading moment.
On October 1st, the PTO and teachers held Family
Reading Night for students in TK – 6th grade and their families from 5:30 – 7:15.!
!
PTO provided pizza dinner for the families attending. Families signed up for two
workshops. Each half-hour workshop started with a short demonstration of a
reading activity by a teacher, followed by parent time to practice the activity with
their child. The workshops were:!
1.! How to help your child figure out unknown words in reading !
2.! How to help your child find a “good fit” book!
3.! How to build comprehension with nonfiction text!
4.! 8 ways to help your child become a better reader!
5.! How to use technology to support literacy!
6.! How to use mindfulness to help with focus and concentration!
7.! Spanish session on reading and comprehension!
During the workshops, eighth grade helpers watched young children in the TK class
with a teacher as supervisor. The night ended with every child selecting a free book
donated by the school and purchased with the help of our librarian, Ms Matas. More
than 250 people – adults and children attended. Family Reading Night was a !
HUGE SUCCESS with teachers, PTO, and families getting together to celebrate
reading as a vital foundation for learning. !
Attendance
In the early grades
Who is affected
Kindergarten and 1st grade classes often have absenteeism rates as high as those in
high school. Many of these absences are excused, but they still add up to lost time in
the classroom.
1 in 10 kids in kindergarten and 1st grade are chronically absent.
In some schools, it’s as high as 1 in 4.
Where is my friend today?
?
Attendance Works.org
*** Teachers and attendance clerks aren’t the only ones who notice your
child isn’t here…
Your child’s peers notice! Students who are not at school regularly leave
their peers with a lack of concern for their peer relationships. Help your
child nurture their education and peer relationships – get your child to
school and on time to help create a good sense of learning and
friendships.
EVERY Day Counts!
~ Start Strong For Success ~
!
!
THE PACIFIC UNION KIWI CATS
SALSA CONTEST WINNERS!
“Elected Official’s Choice Awards”
Supervisor Mark Lovelace’s choice!
(The From left to right: Natalie Clemens, Zoe McCurdy, Alexa Felix, Shontay Crane)
!
Along with several other after-school programs, The PU Kiwi Cats partnered with one of
the many Humboldt County’s finest chefs, Natalia Boyce from Crush Restaurant, to create
their Purrrrfect Plum Salsa. The fun and exciting sixth annual North Coast Youth Culinary
AllStars competition was sponsored by HCOE’s Rising Stars Foundation.
!
Way to go… girls!!!
Party time is here!
Please observe our healthy, nutritional foods below
when providing food for your child’s classroom:
Fresh fruit
Small bags of trail mix
Unbuttered popcorn
Pumpkin or sunflower seeds
Fruit juices
Yogurt with fresh fruit
Peanut butter and celery
Banana bread
Pumpkin bread
Bran and fruit muffins
Pizza-thick crust
Quesadillas – with low fat cheese
Raisins and peanuts
Oatmeal, peanut butter or molasses cookies
Mozzarella (string) cheese sticks
Pretzels
Cereal party mix
Graham crackers
Fruit juice bar
Dried fruits
Fig bars
Frozen yogurt
Fruit
Vegetables
Water with no added sweetener
Milk – 1%, 2% or non-fat
Operation Graditude!
Pacific Union will be participating in Operation
Gratitude this year. Operation Gratitude sends
over 100,000 packages a year to Troops,
Veterans, New Recruits, and Wounded Veterans.
You may participate by donating any candy you
have leftover from Halloween. This may be candy
you purchased and did not distribute or candy
your children received Trick-or-Treating that is
more than you wish to keep at home. Please
send any candy in a plastic bag on November 4th
and 5th. Please send ONLY wrapped candy. We
will send the candy to Operation Gratitude for
their packages.
Thursday & Friday
(November 5th & 6th)
Thank
you
Garden Work Day!
November 4 (Wednesday)
3 – 5 p.m.
Do you have a green thumb?
…purple thumb?
…brown thumb?
Any kind of thumb is WELCOME!
Working in the garden is a GREAT way to meet
new friends and parents of your children.
Please Come ☺
Reading at home….
EVERY%subject%your%child%learns%involves%READING.%Reading%to%your%children%is%enjoyable%for%the%entire%family%and%
opens%the%door%to%educational%success.%Reading%is%an%activity%readily%available%to%everyone%at%no%cost%and%is%a%great%
form%of%entertainment.%Books%are%available%to%check%out%in%our%BEAUTIFUL%library%and%classrooms.%In%addition,%
parents%may%check%out%books%also.%Please%take%advantage%of%the%Arcata%Library%on%TuesdayISaturday.%Go%to%
http://www.humboldtgov.org/213/ArcataILibrary%for%special%events%and%hours.%!
%
According%to%25!Ways!Parents!Can!Read!with!Children,%spending%30%minutes%a%day%reading%books,%magazines%and%
newspapers%are%more%likely%to%become%good%readers.%The%following%are%tips%from%Jim%Trelease’s%The!Read5Aloud!
Handbook:!
• Begin%reading%to%your%child%as%soon%as%possible—no%matter%how%young%your%child%is.%
• Set%aside%time%every%day%for%reading%aloud.%Start%with%just%10%minutes%a%day.%
• Read%stories%that%you%also%enjoy.%
• Vary%the%subject%matter%and%length%of%your%reading.%
• Don’t%confuse%quantity%with%quality.%Your%child%will%remember%10%minutes%of%reading%together%far%longer%
than%your%child%will%remember%two%hours%of%television.%
• Don’t%compete%with%television.%If%you%ask%your%child%if%he/she%would%prefer%a%story%or%TV,%he/she%will%most%
likely%choose%television.%But%remember:%%You’re%the%adult.%Tell%your%child%the%TV%will%be%turned%off%at%7:30.%If%
he/she%wants%a%story,%fine.%If%he%doesn’t,%that’s%okay,%too.%But%don’t%give%your%child%the%idea%that%books%are%
the%reason%he/she%can’t%watch%TV.%
%
NATIONAL NOVEL WRITING MONTH!!!
Does your child love to write, create and eat bagels? We have the place
for them! Come to Writers in the Mist every Wednesday morning at
7:30 a.m. SHARP in Mrs. Loch’s room 23.
Are you looking for a good resource to assist your children with their
writing skills? A great website is
www.factmonster.com/homework/writingskills1.html
Fact Monster’s Homework Center covers:
Essays
Writing Different Types of Essays
How to Write a Biography
How to Write a Book Report
How to Write a Research Paper
How to Write a Bibliography
Sample Term Papers
How to Write a Letter
How to Write a Speech
Spelling & Grammar
Sentence Structure
Help your children enjoy their world of imagination by writing at home!
Conversations in Acceptance…
Movie or NO Movie?
Not sure whether your child is REALLY old enough to see the latest movie?
Go to www.commonsensemedia.org
Throughout her life, your child will encounter and
take note of people who look different than she
does -- whether it's because of weight, height,
shape, or skin color. Regardless of the specifics,
you want your overall message to encourage the
acceptance of all differences, and to discourage
judgment.
Your talking points: "People come in all shapes
and sizes. How they look doesn't make them
better or worse than someone else. How would
you feel if they heard what you were saying?"
Pause to listen to your child's response. "How
would you feel if you were in their body?"
Having your child imagine being in the other
person's shoes will help foster empathy, which is
a crucial component of acceptance.
PARKING LOT SAFETY
Please observe parking lot procedures for the safety of all. Pedestrians,
automobiles, and bicycles all use the parking lot during arrival and
dismissal times. Please use crosswalks, walk your bikes on campus, and
use the drop-off, pick up lanes as intended. Please do not block or park in
the bike lanes or double park blocking cars in at the curbs. Thank you for
helping make those busy times safe!
http://www.bhg.com/better-homes-and-gardenmagazine/good-kid-project/conversations-in-tolerance/
Creative PU Students!
Pacific Union has a STUDENT Newsletter! Starla Ball was the mastermind who
approached Mrs. Loch, the overseeing-newsletter advisor. Our newspaper staff
consists of several energetic and devoted junior high students. The catchy newsletter
called PU Weekly: State of the Union , named by Starla Ball, will eventually be a
weekly newsletter for the entire school! Their first publication was sent out on
October 16, 2015 for the junior high, but will soon be a school-wide paper!
Their cute and clever articles consisted of an interview article from Mrs. Holm; an
update on our girls’ volleyball team; the upcoming school carnival, spaghetti feed; and
creative writings. We can’t wait to see what the next issue brings us. We are proud to
see another successful product from our students and staff at PU!
The PU Weekly: State of the Union writers and editing staff: Nishyra Aaron Williams,
Starla Ball, Morrgin Fedinick Emmons, Amelia Francis, Dexter Gorospe, Endya Humpers,
Maddie Pierce, Alexis Renelle, Kai Riddle-Johnston, and Paloma Tejeda.
(Featured in the October 16, 2015 PU Weekly: State of the Union)
The Land Before Time
Alexis Renelle
A long time ago
Before you and I were born
Creatures roamed about
Big creatures that only live in the land before time
They all died, from an unknown reason.
Maybe the same will happen to us...
Thank you, Mrs. Loch!
Pacific Union School District
School Board Meeting SUMMARY
October 8, 2015
The regular school board meeting was called to order by Mr. T. Weller at 6:00 p.m. on October 8, 2015.
AGENDA ADJUSTMENT: There were no adjustments to the agenda.
CONSENT CALENDAR: It was moved by Emmons and seconded by Collenberg to approve the consent
items. Collenberg, Emmons, Luoma, and Weller voted aye. Motion carried.
PUBLIC CONCERNS:
Ms. Salazar expressed her concern with the proposed Fiesta Night format. She encouraged the use of smaller
groups rather than a lecture format. Ms. Salazar gave suggestions for increasing the number of interpreters that
would be available. She also expressed concern about how parents would be contacted.
REPORTS:
Associate Principal’s Report: Ms. Eckenrode reported on several recent events including Grandparents’ Day,
Family Reading Night, Writers in the Mist, and Walk to School Day. She reported that teachers have been
working together on class studies. Ms. Eckenrode also reported that teachers are implementing SWIS, an
information system that collects data and is helpful in determining the support needed for students. Ms.
Eckenrode gave an update on assemblies and sports. She also reviewed maintenance activities.
Superintendent/Principal’s Report: Mrs. Darnall reported that enrollment is 535. She gave an update on
staffing. Mrs. Darnall reported that there is not a Title III consortium of districts this year due to new
regulations, so the district will not be eligible to receive Title III funding. She informed the board that the
district has been issued a new tax identification number for reporting purposes. Districts previously used the tax
identification number of the Humboldt County Office of Education, but sharing this number could potentially
cause unintended consequences to districts in light of new Affordable Care Act legislation.
Mrs. Darnall reported on the North Coast Schools’ Medical Insurance Group meeting she attended. She
informed the board that medical expenditures for the group are higher than anticipated, but dental and vision
expenditures are lower. Mrs. Darnall reported that an additional classroom set of Chromebooks had been
purchased. She informed the board that one iPad had been stolen. She also reported that Mr. Feist has been
researching new security systems, and she has been gathering information for the replacement of the computer
lab. She reported that improvements to the fire alarm system would be made over Thanksgiving. She also gave
a transportation update. Mrs. Darnall reported that Mr. Moxon has been working on a five-year facility
maintenance plan, and Mr. Feist has been working on a three-year technology infrastructure plan. A school
safety discussion also took place.
Mrs. Darnall updated the board on recent events with Humboldt Educare. She also reported that she has been
working on obtaining a fair market value for the property that Humboldt Educare may be interested in leasing.
INFORMATION/POSSIBLE ACTION ITEMS:
Student Testing: Mrs. Darnall shared a copy of the letter that she sent to parents regarding student testing. Ms.
Eckenrode provided a sample of the testing result information parents would be receiving. She reported that
last year’s scores could be used as a baseline benchmark in the future. Ms. Eckenrode informed the board that
there is room for growth, but improvement is expected as teachers are now using the new adopted math
curriculum that is aligned with the Common Core State Standards. New Language Arts curriculum aligned
with the Common Core State Standards has not been adopted by the state yet, but teachers have been working
hard to develop their own materials in the meantime. Mrs. Darnall also reported that in the future, the state
might increase its focus on student attendance in school and student participation in testing. No action was
taken.
School Board Meeting Minutes October 8, 2015 - continued
Student Email Guidelines: The board reviewed the draft guidelines for student email use. After discussion, it
was suggested that the guidelines be revised and returned to the next meeting for a second reading.
Junior High Handbook: The board reviewed the proposed changes to the Junior High Handbook. Discussion
centered on the grades required for participation in the class trip and the community service requirement. It was
also suggested that the positive reward days be aligned with current field trip policy. Mrs. Darnall will share
the information with the staff, and the handbook will be brought back to the next meeting for a second review.
Future Agenda Planning: The following items were presented as possible items for upcoming agendas: student
email guidelines, Junior High Handbook, Humboldt Area Foundation quarterly statements, County of Humboldt
interest earnings, student technology use board policy, evaluation and final report on Trillium Charter School,
testing update, and Proclamation in Support of the Great American Smokeout.
CORRESPONDENCE/COMMENTS:
The board reviewed the letter from Elijah Moser Murrietta regarding playground equipment and the letter in
response from Mrs. Darnall. The board also reviewed the letter from Naleah Castillo and Starla Ball regarding
fundraising ideas and discussed the response from the board. Mrs. Darnall shared the Public Self-Insurer’s
Annual Report for 2014-15, and she reported per GASB 10 that the funding of the liabilities is in compliance
with the law.
CLOSED SESSION: The board retired to closed session at 7:26 p.m.
OPEN SESSION: The board reconvened open session at 7:46 p.m.
ADJOURNMENT: There being no further business, the board adjourned at 7:46 p.m.
FORMA DE ANTECEDENTES
Evaluación Física Pre-Participación
Fecha del Examen
Nombre: _______________________________________ Sexo: ____
Edad: _________ Fecha de Nac.
__________
____________________
Grado: ___________ Escuela: _______________________________________________ Deporte(s): ______________________
Domicilio: _______________________________________________________________ Teléfono: ________________________
Médico Personal:
_________________________________________________________
Contacto de emergencia: ___________________________________________________
Nombre: __________________________
Explique las preguntas que dijo “Sí”
Encierre en círculo las preguntas “No sé”
Relación: ______________
1. ¿Alguna vez un doctor restringió tu participación en
deportes por alguna razón?
2. ¿Ahora tienes algún problema médico (como asma o
diabetes?
3. ¿Estás tomando medicinas recetadas, o sin receta?
4. ¿Tienes alergias a medicinas, polen, comida, o
piquetes de insectos?
5. ¿Te has desmayado, o casi, DURANTE los ejercicios?
6. ¿Te has desmayado, o casi, DESPUÉS de los
ejercicios?
7. ¿Has sentido incomodidad, dolor, o presión en el
pecho durante los ejercicios?
8. ¿Tu corazón se acelera o da saltos durante el
ejercicio?
9. ¿Te dijo el doctor que tenías: (Marca las que
correspondan)
 Presión alta
 Soplos en el corazón
 Colesterol Alto
 Infección en el corazón
10. ¿Te han ordenado un examen de corazón?
(Electrocardiograma, Ecocardiograma)
11. ¿Alguien de tu familia murió sin causa aparente?
12. ¿Alguien de tu familia tiene problemas de corazón?
13. ¿Alguien de tu familia o pariente murió del corazón,
o de repente antes de 50 años?
14. ¿Alguien de tu familia tiene síndrome de Marfan?
15. ¿Has pasado una noche en un hospital?
16. ¿Te han hecho cirugía?
17.¿Has tenido una lesión, como esguince, desgarre de
ligamento, tendonitis, que impidiera practicar o jugar?
(Marca cuál en los cuadros de abajo).
18. ¿Te has roto un hueso o dislocado alguna articulación?
(Marca cuál en los cuadros de abajo).
19. ¿Te han tomado rayos-X, MRI, CT, cirugía, inyecciones, rehabilitación, terapia física, usado soportes,
yeso, o muletas? (Marca cuál en estos cuadros).
Cabeza
cuello
Hombro
Espalda
alta
Espalda
baja
Cadera
Brazo
superior
muslo
codo
Antebrazo
Mano
dedos
pecho
Rodilla
Pierna
Tobillo
Pie
dedos
20. ¿Has tenido una fractura por ansiedad?
21. ¿Te tomaron rayos-X por inestabilidad atlantoaxial
(de cuello)?
22. ¿Regularmente usas algún tipo de soporte?
23. ¿Tu doctor dijo que tienes asma o alergias?
24. ¿Toses, jadeas, o tienes dificultad para respirar
durante o después del ejercicio?
Sí No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Teléfono: (Casa) ___________ (Trabajo) _____________
25. ¿Alguien en tu familia tiene asma?
26. ¿Has usado un inhalador, o tomado medicina
para el asma?
27. ¿Naciste o te falta un riñón, ojo, testículo, o
algún otro órgano?
28. ¿Has tenido infección de mononucleosis
(mono) durante el último mes?
29. ¿Tienes sarpullido, llagas, u otro tipo de
problema cutáneo?
30. ¿Has tenido infección cutánea herpes?
31. ¿Has sufrido lesión o golpes en la cabeza?
32. ¿Un golpe en la cabeza te provocó confusión o
pérdida de memoria?
33. ¿Has sufrido un ataque?
34. ¿Te duele la cabeza cuando haces ejercicio?
35. ¿Has sentido en brazo o piernas que se te
duermen, te hormiguean, o están débiles
después de ser golpeado o caerte?
36. ¿Has sido incapaz de mover tus brazos o
piernas luego de ser golpeado o caerte?
37. ¿Cuándo ejercitas bajo el sol, sientes
calambres o te sientes mal?
38. ¿El doctor te dijo que tú o alguien en tu familia
tiene anemia hereditaria llamada “sickle cell”?
39. ¿Has tenido problemas con tus ojos o vista?
40. ¿Usas lentes o lentes de contacto?
41. ¿Usas protección de la vista como gogles o una
máscara?
42. ¿Estás contento con tu peso?
43. ¿Estás tratando de ganar o perder peso?
44. ¿Alguien te ha recomendado que cambies tu
peso o hábitos alimenticios?
45. ¿Limitas o controlas cuidadosamente lo que
comes?
46. ¿Quisieras discutir algo con un doctor?
PARA MUJERES SOLAMENTE
47. ¿Has tenido algún período mensual?
48. ¿A qué edad empezaste a menstruar?
49. ¿Cuántos períodos tuviste durante los
últimos 12 meses?
Explica las contestaciones “Sí” aquí:
Sí No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
____
____
 
 
 
Por este medio, certifico que hasta donde yo sé, mis respuestas a las preguntas mencionadas están completas y correctas.
Firma del atleta ___________________________ Firma del padre/tutor ________________________ Fecha ________________
JPA 24/Spanish, Página 1
COPIAS:
Blanca: a los Padres
Amarilla: Oficina del Distrito
Rosa: Director de Atletismo
FORMA DE EXAMEN FÍSICO
Nombre: ________________________________________________ Fecha de Nacimiento: ________________________________
Estatura: ________ Peso: ______ % de Grasa Corporal (opcional):______
Vista Der.20/___
Iz. 20/___
Corregida: Sí___ No___
Pulso_____
Pupilas Iguales: _____
BP ___/___ ( ___/___,___/___)
Desiguales: ____
Seguimiento sobre Aspectos más Importantes
1. ¿ Te sientes agobiado o bajo mucha presión?
2. ¿A veces te sientes tan triste o desesperanzado que dejas de hacer alguna de tus actividades normales
durante más de unos cuantos días?
3. ¿Te sientes seguro?
4. ¿Has tratado de fumar, aún una o dos fumadas? ¿Estás fumando?
5. ¿Durante los últimos 30 días, mascaste tabaco, snuff (inhalar) o dip (colocar en bolsita en la encía)?
6.
7.
8.
¿Durante los últimos 30 días, bebiste cuando menos un trago de licor, cerveza, etc.?
¿Has tomado alguna vez píldoras de esteroides, o inyecciones sin receta médica?
¿Has tomado alguna vez suplementos para ayudarte o subir o bajar de peso o mejorar tu rendimiento?
Sí


No





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NOTAS: ___________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
NORMAL
ANORMALIDADES ENCONTRADAS*
INICIALES*
MÉDICA
Apariencia
Ojos/oídos/nariz/garganta
Oído
Módulos linfáticos
Corazón
Soplos cardíacos
Pulso
Pulmones
Abdomen
Genitourinario (sólo hombres)**
Piel
MUSCULOESQUELÉTICO
Cuello
Espalda
Hombro/brazo
Codo/antebrazo
Muñeca/mano/dedos
Cadera/muslo
Rodilla
Pierna/tobillo
Pie/dedos
* Sólo practicado por múltiples examinadores.
** Para hacer el examen genitourinario se recomienda que haya una tercera persona presente.
NOTAS: __________________________________________________________________________________________________
________________________________________________________________________________________________________
Participación en los Deportes: Aprobada:____
Condicional:_____
Negada:____
Nombre del Médico (con letras de molde): ________________________________________________
Fecha: _______________
Domicilio: __________________________________________________________________________ Teléfono: _____________
Firma del Médico: _______________________________________________________________________, MD, DO, ND, NP, O PA
JPA 24/Spanish, Página 2
Copias: Blanca:Padres
Amarilla: Oficina del Distrito
Rosa: Director de Atletismo
Comctrfiles/ncsig/forms/JPA_24_Physical Eval/3/08 07/2010/Spa
HISTORY FORM
Preparticipation Physical Evaluation
DATE OF EXAM
Name
Grade
School
Address
Personal Physician
In Case of Emergency, Contact
Name
Relationship
Sex
Age
Date of Birth
Sport(s)
Phone
Phone (H)
(W)
Explain “Yes” answers below.
Circle questions you don’t know the answers to:
Yes No
Yes No
1. Has a doctor ever denied or restricted your
participation in sports for any reason?
2. Do you have an ongoing medical condition
(like diabetes or asthma)?
3. Are you currently taking any prescription or
nonprescription (over-the-counter) medicines or pills?
4. Do you have allergies to medicines, pollens, foods, or
stinging insects?
5. Have you ever passed out or nearly passed out
DURING exercise?
6. Have you ever passed out or nearly passed out
AFTER exercise?
7. Have you ever had discomfort, pain, or pressure in your
chest during exercise?
8. Does your heart race or skip beats during exercise?
9. Has a doctor ever told you that you have
(check all that apply):
High blood pressure
A heart murmur
High cholesterol
A heart infection
10. Has a doctor ever ordered a test for your heart?
(for example, ECG, echocardiogram)
11. Has anyone in your family died for no apparent reason?
12. Does anyone in your family have a heart problem?
13. Has any family member or relative died of heart
problems or of sudden death before age 50?
14. Does anyone in your family have Marfan syndrome?
15. Have you ever spent the night in a hospital?
16. Have you ever had surgery?
17. Have you ever had an injury, like a sprain, muscle or
ligament tear, or tendinitis, that caused you to miss a
practice or game? If yes, circle affected area below:
18. Have you had any broken or fractured bones or
dislocated joints? If yes, circle below:
19. Have you had a bone or joint injury that required x-rays,
MRI, CT, surgery, injections, rehabilitation, physical
therapy, a brace, a cast, or crutches? If yes, circle
below:
Head
Neck
Upper Lower
back
back
Shoulder
Upper
Elbow
Forearm
Hand/
Chest
Hip
Thigh
Knee
Calf/shin
Ankle
Foot/toes
25. Is there anyone in your family who has asthma?
26. Have you ever used an inhaler or taken asthma medicine?
27. Were you born without or are you missing a kidney,
an eye, a testicle, or any other organ?
28. Have you had infectious mononucleosis (mono)
within the last month?
29. Do you have any rashes, pressure sores, or other
skin problems?
30. Have you had a herpes skin infection?
31. Have you ever had a head injury or concussion?
32. Have you been hit in the head and been confused
or lost your memory?
33. Have you ever had a seizure?
34. Do you have headaches with exercise?
35. Have you ever had numbness, tingling, or weakness
in your arms or legs after being hit or falling?
36. Have you ever been unable to move your arms or legs after
being hit or falling?
37. When exercising in the heat, do you have severe muscle
cramps or become ill?
38. Has a doctor told you that you or someone in your
family has sickle cell trait or sickle cell disease?
39. Have you had any problems with your eyes or vision?
40. Do you wear glasses or contact lenses?
41. Do you wear protective eyewear, such as goggles or
a face shield?
42. Are you happy with your weight?
43. Are you trying to gain or lose weight?
44. Has anyone recommended you change your weight
or eating habits?
45. Do you limit or carefully control what you eat?
46. Do you have any concerns that you would like to
discuss with a doctor?
FEMALES ONLY
47. Have you ever had a menstrual period?
49. How many periods have you had in the last 12 months?
Explain “YES” answers here:
20. Have you ever had a stress fracture?
21. Have you been told that you have or have you had
an x-ray for atlantoaxial (neck) instability?
22. Do you regularly use a brace or assistive device?
23. Has a doctor ever told you that you have asthma
or allergies?
during or after exercise?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete
Signature of parent/guardian
Date
JPA 24, Page 1
PHYSICAL EXAMINATION FORM
Preparticipation Physical Evaluation
Name
Date of birth
Height
Weight
Vision R 20/
L 20/
% Body fat (optional)
Corrected: Y N
Pulse
Pupils: Equal
BP
/
(
/
,
/
)
Unequal
Follow-Up Questions on More Sensitive Issues
1. Do you feel stressed out or under a lot of pressure?
2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days?
3. Do you feel safe?
4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke?
5. During the past 30 days, did you use chewing tobacco, snuff, or dip?
6. During the past 30 days, have you had at least 1 drink of alcohol?
7. Have you ever taken steroid pills or shots without a doctor’s prescription?
8. Have you ever taken any supplements to help you gain or lose weight or improve your performance?
Yes No
Notes:
NORMAL
ABNORMAL FINDINGS
INITIALS *
MEDICAL
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary (males only)* *
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Hip/thigh
Knee
Leg/ankle
Foot/toes
* Multiple-examiner set-up only.
* * Having a third party present is recommended for the genitourinary examination.
Notes:
Name of physician (print/type)
Address
Signature of physician
Date
Phone
, MD, DO, ND, NP or PA
JPA 24, Page 2
Pacific Union School Events
Sun
Nov 2 0 15 ( Paci f i c T i me)
Mon
1
Tue
2
Wed
3
Election Day
9
10
GBB - PU @
SunnyBrae
15
4
6 p m - PTO @
Debbie's Big
Kid Room
GBB - McK @ PU
8
16
Thu
5
GBB - Zane @ PU
11
17
Sat
6
7
13
14
20
21
27
28
4
5
A to Z Eyecare
Learn to Earn
Veterans' Day-No
School
GBB - PU @ Jacoby
Creek
Fri
12
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Learn to Earn
6 p m - Bd Meeting @
Computer Lab
18
3 : 3 0 p m - Site
Council @
PCR
19
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End 1st Trimester
Learn to Earn
Munch-a-Lunch
9 a m - Primary
Awards
22
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24
25
26
THANKS GIVING BREAK - NO SCHOOL
29
30
1
GBB - PU @ Zane
2
6 p m - PTO @
Debbie's Big
Kid Room
3
GBB - SunnyBrae @
PU
A to Z Eyecare
Learn to Earn