Physical Evaluation Form
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1
2
3PHYSICAL EVALUATION
Date of Exam: ______________________
Name: _________________________________________________ Gender: ____ Age: _____ Date of Birth: ___________________
Grade: _____ School: ___________________________ Sport(s): ______________________________________________________
Address: ___________________________________________________________________Phone:___________________________
Personal Physician: ______________________________Phone:_______________________________________________________
In Case of Emergency Contact:
Name: _________________________ Relationship: ___________________ Phone (H):_____________ (W) ___________________
(C) ___________________
Please answer all questions below. Explain any “Yes” Answer in the space provided and Circle any question you don’t know the
answer to.
1.
Has a doctor ever denied or restricted your participation in sports for any reason?
Yes
No
2.
Do you have an ongoing medical condition like diabetes, asthma, or high blood
Yes
No
MEDICATIONS:
pressure?
3.
Do you have any allergies to medications, pollens, foods, or stinging insects?
Yes
No
1. _____________________________
4.
Have you ever passed out or nearly passed out during or after exercise?
Yes
No
2. _____________________________
5.
Have you ever had discomfort, pain, or pressure in your chest during exercise?
Yes
No
3. ____________________________
6.
Does your heart race or skip beats during exercise?
Yes
No
4. ____________________________
7.
Has a doctor ever ordered a test for your heart called an EKG?
Yes
No
8.
Has anyone in your family died of a heart problem before age 50?
Yes
No
ALLERGIES:
Does anyone in your family have Marfan’s Syndrome?
9.
Yes
No
10. Have you ever spent the night in the hospital?
Yes
No
1. ______________________________
11. Have you ever had surgery?
Yes
No
2.______________________________
12. Have you ever had an injury that caused you to miss a practice or game?
Yes
No
3.______________________________
13. Have you ever had a broken or dislocated bone?
Yes
No
14. Do you regularly use a brace or other assistive device?
Yes
No
15. Has a doctor ever told you that you have asthma or allergies?
Yes
No
16. Do you cough, wheeze, or have difficulty breathing during exercise?
Yes
No
17. Have you ever used an inhaler or taken asthma medicines?
Yes
No
18. Were you born without or are you missing a kidney, eye, a testicle
Yes
No
or any other organ?
19. Have you had infectious mononucleosis (mono) in the last month?
Yes
No
20. Do you have any rashes or other skin problems?
Yes
No
21. Have you had a herpes skin infection?
Yes
No
22. Have you ever had a concussion?
Yes
No
23. Have you ever hit your head and been confused or lost your memory?
Yes
No
24. Do you have headaches with exercise?
Yes
No
25. Have you ever had weakness, numbness or tingling after being hit or falling?
Yes
No
26. Have you ever had a seizure?
Yes
No
27. When exercising in the heat, do you have muscle cramps and become ill?
Yes
No
28. Has a doctor told you or anyone in your family that they have sickle cell trait
Yes
No
or sickle cell disease?
29. Have you had any problem with your eyes or vision?
Yes
No
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