Athletic Participation/parental Consent/physical Examination Form Page 2
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4PART II - - MEDICAL HISTORY
This form must be completed by parent or guardian prior to the physical examination and should be taken with the
physical examination form for review by the physician during the examination.
YES
NO
1.
Have you ever had any of the following?
Please explain any YES answers
____
____
heart murmur ________________________________________________________________
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____
high blood pressure ___________________________________________________________
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____
other heart problems _________________________________________________________
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____
broken bones ________________________________________________________________
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weak joints-ankles, knees ____________________________________________________
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concussion __________________________________________________________________
____
____
operation ____________________________________________________________________
____
____
seizures or epilepsy __________________________________________________________
____
____
2.
Have you ever fainted or passed out? _________________________________________
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3.
Have you ever been knocked out? ____________________________________________
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____
4.
Have you ever been hospitalized? ____________________________________________
____
____
5.
Have you ever had to stop running after ¼ to ½
miles for chest pain or shortness of breath? __________________________________
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6.
A. Have you ever had significant allergies to:
____
____
bee stings? – On medication – yes___ no___ ___________________________
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____
foods ________________________________________________________________
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medicine _____________________________________________________________
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others _______________________________________________________________
B. Do you have prescription for use of:
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Adrenaline ___________________________________________________________
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Inhalers _____________________________________________________________
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Other allergy medicine _______________________________________________
____
____
C. Do you have asthma? ____________________________________________________
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7.
Do you take any medicine regularly? ________________________________________
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____
8.
Have you had any illnesses lasting a week or more
such as mononucleosis, etc.? _______________________________________________
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____
9.
Have you had any blood disorders, including sickle
cell trait, anemia, etc.? ______________________________________________________
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____
10.
Has any family member had a heart attack, hear problems or
sudden death before the age of 50? ___________________________________________
____
____
11.
Do you wear contact lenses, eyeglasses or dental
appliance? ___________________________________________________________________
____
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12.
Do you have any missing or non-functioning organs
such as testes, eye, kidney, etc.? _____________________________________________
13.
Menstrual History:
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____
Have you begun menses yet? _________________________________________________
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____
14.
Do you have any other significant health problems? ___________________________
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____
15.
Hepatitis B Immunization Series? _____________________________________________
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16.
DATE OF LAST TETNUS IMMUNIZATION? _____________________________________
Parent/Guardian Signature: ____________________________________
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