Sports Medical History And Exam Form

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SPORTS PHYSICAL
Date ________________ FIRST NAME ________________________________________ LAST NAME _____________________________________
Grade _________ Sex _________ Birthdate ______________ Age ________ Parent/Guardian ________________________________________________
Address __________________________ City ______________ Zip _____________Phone(H) ____________________ (W) ______________________
THIS MEDICAL HISTORY AND EXAM IS ONLY INTENDED TO DETERMINE ABILITY TO PARTICIPATE IN SPORTS AND IS NOT A SUBSTI-
TUTE FOR REGULAR EXAMS BY YOUR PHYSICIAN.
Date of Tetanus Immunization (Required every 10 years)____________________ Hepatitis B_________________
Have you ever had or do you have any of the following:
YES
NO
Y
N
1)
Head injury, concussion, loss of memory, loss of consciousness during exercise
Y
N
2)
Back or neck problems or curvature of the spine, corrective devices
Y
N
3)
Broken bones, dislocation, or amputations, sprains, strains
Y
N
4)
Problems with foot, knee or other joints, numbness or tingling in extremities
Y
N
5)
Eye injury, eye surgery, eye disease
Y
N
6)
Wear glasses, contacts, hearing aid, dentures or dental appliances (braces, retainer)
Y
N
7)
Headaches-other than minor headaches
Y
N
8)
Drug addiction, mental illness, nervous disorder
Y
N
9)
Epilepsy, seizures, fainting, or dizzy spells
Y
N
10)
Lung trouble, shortness of breath, asthma, allergies, inhaler, wheezing during exercise
Y
N
11)
Heart trouble, rheumatic fever, high blood pressure, chest pain with exercise, heart murmur
Y
N
12)
Anemia, leukemia or any blood disorder
Y
N
13)
Diabetes, hypoglycemia, excessive thirst
Y
N
14)
Hernia, kidney problem, testicle problem
Y
N
15)
Enlarged spleen or liver or severe viral infection
Y
N
16)
Surgery or hospitalization
Y
N
17)
Family history of sudden death or heart-related death before age of 50
Y
N
18)
Presently taking any medication, supplements, vitamins (list below)
Y
N
19)
Allergic to medicine, foods, insect bites or stings, tape ect.
Y
N
20)
Skin problems (rashes, hives, ringworm, fungus)
Y
N
21)
Heat stroke, heat exhaustion, ill from exercise in the heat
Y
N
22)
Do you have any ongoing medical problems or reasons you should not participate
Please explain any Yes Answers: ________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
EMERGENCY INFORMATION:
Person to contact if parents cannot be reached _______________________________________________Phone__________________________________
Family Physician ______________________________________________________________________Phone__________________________________
PHYSICAL EXAM
Height __________________
Weight _______________
Blood Pressure ______________________
Pulse ______________________
Normal
Abnormal
Normal
Abnormal
________
_________
1) General Appearance
_________
_________
6) Cardiovascular
________
_________
2) Eyes, Teeth, ENT
_________
_________
7) Abdomen
________
_________
3) Neurological
_________
_________
8) Hernia/Genitalia
________
_________
4) Lymph Nodes
_________
_________
9) Spine, neck, back
________
_________
5) Respiratory
_________
_________
10) Musculo-skeletal
_________
_________
11) Menses
Recommendation:
Comments:
__________ Fully Participate
________________________________________________________
__________ No Participation
________________________________________________________
__________ Able to participate with the following limitations:
________________________________________________________
1. ___________________________________________________
________________________________________________________
2. ___________________________________________________
________________________________________________________
Physician Signature ________________________________________________________________________ Date ___________________________

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