Physical Form - Mt. Lebanon School District (Page 2 of 3) in pdf

PARENTS MUST COMPLETE AND ATTACH SECTION 5 TO PHYSICAL PAGE FROM PHYSICIAN

Student’s Name

Age

Grade

SECTION 5: HEALTH HISTORY

Explain “Yes” answers at the bottom of this form.

Circle questions you don’t know the answers to.

Yes

1. Has a doctor ever denied or restricted your

23. Has a doctor every told you that you have

participation in sport(s) for any reason?

asthma or allergies?

2. Do you have an ongoing medical condition

24. Do you cough, wheeze, or have difficulty

(like asthma or diabetes)?

breathing DURING or AFTER exercise?

3. Are you currently taking any prescription or

25. Is there anyone in your family who has

nonprescription (over-the-counter) medicines

asthma?

or pills?

26. Have you ever used an inhaler or taken

4. Do you have allergies to medicines, pollens,

asthma medicine?

foods, or stinging insects?

27. Were you born without or are your missing a

5. Have you ever passed out or nearly passed

kidney, an eye, a testicle, or any other organ?

out DURING exercise?

28. Have you had infectious mononucleosis

6. Have you ever passed out or nearly passed

(mono) within the last month?

out AFTER exercise?

29. Do you have any rashes, pressure sores, or

7. Have you ever had discomfort, pain, or

other skin problems?

pressure in your chest during exercise?

30. Have you had a herpes skin infection?

8. Does your heart race or skip beats during

CONCUSSION OR TRAUMATIC BRAIN INJURY

exercise?

31. Have you ever had a concussion (i.e. bell rung,

9. Has a doctor ever told you that you have

ding, head rush) or traumatic brain injury?

(check all that apply):

32. Have you been hit in the head and been

High blood pressure

Heart murmur

confused or lost your memory?

High cholesterol

Heart infection

33.Do you experience dizziness and/or

10. Has a doctor ever ordered a test for your

headaches with exercise?

heart? (for example ECG, echocardiogram)

34. Have you ever had a seizure?

11. Has anyone in your family died for no

35. Have you ever had numbness, tingling, or

apparent reason?

weakness in your arms or legs after being hit

12. Does anyone in your family have a heart

or falling?

problem?

36. Have you ever been unable to move your

13. Has any family member or relative died of

arms or legs after being hit or failing?

heart problems or of sudden death before

37. When exercising in the heat, do you have

age 50?

severe muscle cramps or become ill?

14. Does anyone in your family have Marfan

38. Has a doctor told you that you or someone in

syndrome?

your family has sickle cell trait or sickle cell

15. Have you ever spent the night in a hospital?

disease?

16. Have you ever had surgery?

39. Have you had any problems with your eyes or

17. Have you ever had an injury, like a sprain,

vision?

muscle, or ligament tear, or tendonitis, that

40. Do you wear glasses or contact lenses?

caused you to miss a practice or Contest?

41. Do you wear protective eyewear, such as

If yes, circle affected area below:

goggles or a face shield?

18. Have you had any broken or fractured bones

42. Are you unhappy with your weight?

or dislocated joints? If yes, circle below:

43. Are you trying to gain or lose weight?

19. Have you had a bone or joint injury that

44. Has anyone recommended you change your

required x-rays, MRI, CT, surgery, injections,

weight or eating habits?

rehabilitation, physical therapy, a brace, a

45. Do you limit or carefully control what you eat?

cast, or crutches? If yes, circle below:

46. Do you have any concerns that you would

like to discuss with a doctor?

Head

Neck

Shoulder

Upper

Elbow

Forearm

Hand/

Chest

arm

Fingers

FEMALES ONLY

Upper

Lower

Hip

Thigh

Knee

Calf/shin

Ankle

Foot/

47. Have you ever had a menstrual period?

back

Toes

48. How old were you when you had your first

20. Have you ever had a stress fracture?

menstrual period?

21. Have you been told that you have or have

49. How many periods have you had in the last

you had an x-ray for atlantoaxial (neck)

12 months?

instability?

50. Are you pregnant?

22. Do you regularly use a brace or assistive device?

#’s

Explain “Yes” answers here:

I hereby certify that to the best of my knowledge all of the information herein is true and complete.

Student’s Signature _________________________________________________________________________Date____/____/_____

I hereby certify that to the best of my knowledge all of the information herein is true and complete.

Parent’s/Guardian’s Signature _________________________________________________________________Date____/____/_____

Physical Form - Mt. Lebanon School District Page 2

Related Articles

Related forms

Related Categories