Sports Physical Forms

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SCHOOL BOARD OF SEMINOLE COUNTY, FL
MIDDLE SCHOOL
SPORTS SCREENING/PHYSICAL & PARENT/STUDENT RELEASE FORM
PART 1. Student information (to be completed by student or parent)
Student's Name:____________________________________________________________ Sex: _____ Age: _______ Date of Birth: ____/____/____
Grade ____ Home Phone: (
) _______________Work (
)___________________Cell (
)__________________________
Home Address: ___________________________________,_______________Legal Name of Parent/Guardian: ________________________________
City
Emergency Contact ____________________ Relationship to Student: __________ Home # (_____) _________ Work # (_____) ________________
Family Physician: __________________________City _____________ Office Phone: (_____) ____________Previous School_________________
PART 2: Verification of medical insurance:
Insurance coverage is required for participation in athletic events. Athletes must have personal insurance coverage or school purchased
insurance. School insurance covers all sports.
My child/ward is covered under a family policy, which has limits $ 25,000, or school purchased policy. Sport(s) played ____________________________________________________________
Individual Insurance
Company Name________________________________________
Policy #___________________________________
School Insurance
Company Name________________________________________
Policy #___________________________________
PART 3: Medical History
to be completed by student or parent. Explain "yes" answers on separate page. Please circle any questions you are unable to answer.
Yes
No
Yes
No
1. Have you had a medical illness or injury since your last check or sports physical?
28. Do you have asthma?
2. Do you have an ongoing chronic illness?
29. Do you have seasonal allergies that require medical treatment?
3. Have you ever been hospitalized overnight?
30. Do you use any special protective or corrective equipment or
4. Have you ever had surgery?
devices that aren't usually used for your sport or position (for
5. Are you currently taking any prescription or nonprescription (over the counter)
example, knee brace, special neck roll, foot orthotics, retainer
medications or pills or using an inhaler?
on your teeth, hearing aid)?
6. Have you ever taken any supplements or vitamins to help you gain or lose
31. Have you had any problems with your eyes or vision?
weight or improve your performance?
32. Do you wear glasses, contacts, or protective eyewear?
7. Do you have any allergies, for example(pollen, medicine, food or stinging insects)?
33. Have you ever had a sprain, strain, or swelling after injury?
8. Have you ever had a rash or hives develop during or after exercise?
34. Have you broken or fractured any bones or dislocated any joints?
9. Have you ever passed out during or after exercise?
35. Have you had any other problems with pain or swelling in muscles,
10. Have you ever been dizzy during or after exercise?
tendons, bones, or joints?
11. Have you ever had chest pain during or after exercise?
If yes, check appropriate blank and explain below.
12. Do you get tired more quickly than your friends do during exercise?
___Head
___Elbow
___Hip
___Neck ___Ankle
13. Have you ever had racing of your heart or skipped heartbeats?
___Thigh
___Back
___Wrist
___Knee
14. Have you had high blood pressure or high cholesterol?
___Hand
___Shin/Calf ___Shoulder ___Finger
15. Have you ever been told you have a heart murmur?
___Upper Arm ___Foot
___Forearm
___Chest
16. Has any family member or relative died of heart problems or sudden death
before age 50?
36. Do you want to weigh more or less than you do now?
17. Have you had a severe viral infection ( for example, myocarditis or
37. Do you lose weight regularly to meet weight requirements for your
mononucleosis) within the month?
sport?
18. Has a physician ever denied or restricted your participation in sports for any
38. Do you feel stressed out?
heart problems.?
39. Record the dates of your most recent immunizations (shots) for:
19. Do you have any current skin problems ( for example, itching, rashes, acne, warts,
Tetanus:___________________ Measles:___________________
fungus, or blisters)?
Hepatitis B: ________________ Chickenpox:_________________
20. Have you ever had a head injury or concussion?
21. Have you ever been knocked out, become unconscious, or lost your memory?
Females Only (optional)
22. Have you ever had a seizure?
40. When was your first menstrual period?_______________________
23. Do you have frequent or severe headaches?
41. When was your most recent menstrual period?_________________
24. Have you ever had numbness or tingling in your arms, hands, legs, or feet?
42. How much time do you usually have from the start of one period to
25. Have you ever had a stinger, burner, or pinched nerve?
the start of another?_____________________________________
26. Have you ever become ill from exercising in the heat?
43. How many periods have you had in the last year?_______________
27. Do you cough, wheeze, or have trouble breathing during or after activity?
44. What was the longest time between periods in the last year?_______
PART 4:
Examination
Physical
(to be completed by physician).
Student's Name: __________________________________________________________________________________ Date of Birth: ____/____/____ Height: __________ Weight: __________
% Body Fat (optional): __________ Pulse: __________ Blood Pressure: _____/_____ ( _____ / _____ . _____ / _____) Visual Acuity: Right 20/ _____ Left 20/_____ Corrected : Yes No
Pupils: Equal __________ Unequal __________
FINDINGS
NORMAL ABNORMAL FINDINGS INITIALS
NORMAL ABNORMAL INITIALS
NORMAL
ABNORMAL INITIALS
MUSCULOSKELETAL
9. Foot
________ ______________ ______
1. Neck
_______
________________ _______
10.Appearance
________ _____________ ______
16.E/E/N/T ______ ____________ _____
2. Back
_______
_______________ _______
MEDICAL
17.Skin
______ ____________ ______
3. Shoulder/Arm
_______
_______________ _______
11. Heart
________ ____________ _ ______
18.Genitalia (Males only)
4. Elbow/Forearm
_______
_______________
_______
12. Pulses
________ _____________ ______
______ ____________ _____
6. Hip/Thigh
_______
_______________ _______
13. Lymph Nodes
________ _____________ _______
7. Knee
_______
_______________ _______
14. Lungs
________ _____________ _______
8. Leg/Ankle
_______
_______________ _______
15. Abdomen
________ _____________ ________

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