Student Medical Report
Student’s Name _______________________________________________________________________
(Last)
(First)
(Middle)
(Nickname)
Birth date _____________
Sex (male or female) _________________________
Name of Parent(s)/Guardian(s) _______________________Phone (h) ____________ (w) ___________
________________________________________________Phone (h) ____________ (w) ___________
To be completed by the parent/guardian of a student participating in athletics
Please explain any
“Yes” answers.
1. Has your child had an illness or injury in the past year? Y __ N __
_________________________________________________________________________________________
2. Has your child been hospitalized or had surgery? Y __ N __
_________________________________________________________________________________________
3. Is your child currently taking any prescription or over the counter medications or using an inhaler? Y __ N __
_________________________________________________________________________________________
4. Does your child have allergies to food? Y __ N __ Medicines? Y __ N __ Stinging insects? Y __ N __
_________________________________________________________________________________________
5. a. Has your child ever passed out? Y __ N __
b. Has your child ever been dizzy during or after exercise? Y __ N __
c. Has your child ever had chest pain during or after exercise? Y __ N __
d Does your child tire more quickly than his/her friends during exercise? Y __ N __
e. Has your child ever had a racing heart or felt his/her heart skip a beat? Y __ N __
f. Does your child have high blood pressure or cholesterol? Y __ N __
g. Has your child ever been told he/she has a heart murmur? Y __ N __
h. Has any family member died of heart problems or sudden death prior to age 50? Y __ N __
i. Has your child had a severe viral infection within the past month? Y __ N __
j. Has a physician ever denied or restricted his/her participation in sports for any heart problems? Y __ N __
_________________________________________________________________________________________
6. Does your child have any current skin problems? Y __ N __
_________________________________________________________________________________________
7. a. Has your child ever had a head injury or a concussion? Y __ N __
b. Has your child ever been knocked out, become unconscious, or lost his/her memory? Y __ N __
c. Has your child ever had a seizure? Y __ N __
d. Does your child have frequent or severe headaches? Y __ N __
e. Has your child ever had numbness, tingling in his/her arms, hands, legs or feet? Y __ N __
f. Has your child ever had a stinger, burner or pinched nerve? Y __ N __
_________________________________________________________________________________________
8. Has your child ever become ill from exercising in the heat? Y __ N __
_________________________________________________________________________________________
9. Does your child have asthma or seasonal allergies that require medication or inhibit his/her ability to exercise?
Y __ N __
_________________________________________________________________________________________
10. Does your child use any protective equipment or braces not usually used in sports? Y __ N __
_________________________________________________________________________________________
11. Does your child have any vision problems? Y __ N __ Does your child wear contacts or glasses? Y __ N __
_________________________________________________________________________________________
12. Has your child ever had a sprain, strain or swelling after injury? Y __ N __
_________________________________________________________________________________________
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