Medical History Questionnaire Form Page 2
ADVERTISEMENT
1
2Medical History Questionnaire
(page 2 of 2)
Student’s Name ____________________________________________
Consent Form to Self-Administer Asthma Medication
Parent Consent
I, ____________________________________, do hereby give my son/daughter, ____________________________________,
permission to self-administer his/her asthma medication as prescribed by his/her physician during athletic competition.
_________________________________________________________
_____________________________________
Parent’s Signature (if student-athlete is under 18 years of age)
Date
Physician Consent
As a patient under my care, ___________________________________, is prescribed to self-administer the following asthma
medication:
Medication __________________________________________ Purpose ___________________________________________
Dosage _____________________________________________ Time/ Special Circumstances ___________________________
_________________________________________________________
_____________________________________
Physician’s Signature
Date
Physical Examination
Height ________________________
Weight __________________
Blood Pressure ________________________
Pulse: Resting __________________
15 hops _________________
after 2 minutes resting _________________
Visual Acuity:
Eyes (R) 20/__________ w/o glasses __________ (L) 20/__________ w/glasses __________
Other Testing
Normal Abnormal Findings
Normal Abnormal Findings
1. General
_____
____________________
13. Marfan Screen
_____
_____________________
2. Skin
_____
____________________
14. Musculoskeletal
3. HEENT
_____
____________________
Neck
_____
_____________________
4. Teeth (Dental Exam)
_____
____________________
Shoulder/Arm
_____
_____________________
5. Neck
_____
____________________
Elbow/Forearm
_____
_____________________
6. Lungs
_____
____________________
Wrist/Hand
_____
_____________________
7. Heart (sit and stand)
_____
____________________
Back
_____
_____________________
8. Abdomen
_____
____________________
Hip/Thigh
_____
_____________________
9. Genitalia
_____
____________________
Knee
_____
_____________________
10. Peripheral Pulses
_____
____________________
Shin/Calf
_____
_____________________
11. Neurologic
_____
____________________
Ankle/Leg
_____
_____________________
12. Mental Status
_____
____________________
Foot
_____
_____________________
On the basis of the examination on this day, I approve this student’s participation in intercollegiate sports for one year.
Yes __________
No__________
Limited__________
Additional Comments/Recommendations for Handling Above Abnormalities: _______________________________________
______________________________________________________________________________________________________
Physician’s Name________________________________ Address ____________________________Phone _______________
Physician’s Signature _____________________________________ Date of Examination _____________________________
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical