Medical History Form printable pdf download

MEDICAL HISTORY FORM

Student name______________________________________Date________________Period_________

STUDENT PORTION (this part must be filled out by the student)

Please check off if you have ever had the following AND had to go to a doctor about:

Asthma_____(do you have an inhaler?_______ ) Diabetes _____ Hear Murmur _____ Hernia______

Heart problems_____ Anemia _____ High Blood Pressure _____

Other________________________

Any type of surgery (what type and when): __________________________________________________

Any type of joint injury (ankle, knees, shoulder, etc.) in the last 2 years (what and when and how):

_____________________________________________________________________________________

Are you currently on any type of medication for a physical illness or injury? yes_____

no _____

If yes, what is it and what is it for? _______________________________________________________

*************************************************************************************

PARENT PORTION (this part must be filled out by the parent ONLY)

Parent name_______________________________________ Relationship _______________________

Please read over the above information medical history form that your child has filled out. It is important

for me as your child’s physical education teacher to be aware of any problems that may effect his or her

participation in my class.

Please describe on the lines below any medical problems and/or medications that your child currently has

or is taking that will affect his or her participation in my class (this should confirm what your child filled

out above). If they have no medical problems, please indicate that on this form as well. If your child’s

problem is something that may need me to modify the activity in my class, a doctor’s note will need to

accompany this form.

_____________________________________________________________________________________

Furthermore, if your child is sick or injured at some point while taking my physical education class,

please write him or her a note to bring to me so I can excuse them from participation for one day. If

he/she will need to be excused for more than one day, it is department policy that the teacher is provided

with a doctor’s note.

Yours in health and fitness,

Ms. Marcy

Parent Signature _____________________________________________Date_____________________

Medical History Form