Athletic Competition Health Screening Form
ADVERTISEMENT
1
2
3THE AMERICAN ACADEMY OF FAMILY PHYSICIANS
Athletic Competition Health Screening Form
NAME:
SCHOOL:
AGE:
GRADE
BIRTHDATE:
SEX:
Health History:
Family Physician:
The information below is current and correct to
Address:
Phone:
the best of my knowledge.
City:
Zip:
Signature of Parent/Guardian
SATISFACTORY
VITALS
PHYSICAL
RECOMMENDED
Answer yes or no only
YES
NO
EVALUATION
FOLLOW-UP
COMMENTS
YES
NO
Family history of sudden cardiac
death
Ht:
Chronic/Recurrent illness
Wt:
Hospitalization
BP:
Surgery other than tonsils
GENERAL
Injuries treated by physician
Head
Current medication
Eyes
Acuity: L
R
Organs missing
ENT
Dizziness, fainting, convulsions
Dental
and/or headaches
Concussion or knocked out
Chest
Has athlete ever had a seizure
Heart
Wear glasses/contacts
Abdomen
Hearing defects
Genitalia
Dental appliances of any kind
Skin
Cough pain
Extremities,
Problems with blood pressure
Back, Neck
Problems with liver, spleen,
kidneys
Hernia
SPORTS PARTICIPATION APPROVED
Recurrent skin disease
Bone/joint injury
YES_____________
NO___________
Sprain/dislocation
Limitations:
Injury that caused a missed
practice or game
_______________________________________________
Allergies
Comments:
Allergy to medications
_______________________________________________
If yes above, what meds?
Asthma
Physician Signature: ______________________________
Does athlete use inhaler
Tetanus booster in last 10 yrs.
Date: _____/_______/20____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical