Officials Physical Examination Form
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1W
V
S
S
A
C
EST
IRGINIA
ECONDARY
CHOOL
CTIVITIES
OMMISSION
PHYSICAL EXAMINATION FOR OFFICIALS – Recommended Yearly
(To Be Completed by Official BEFORE Examination - Please Type or Print)
Name _________________________________ Reg. # ______________________ Local Board ___________________
(Last)
(First)
(M)
Home Address _______________________________________________________ Telephone ____________________
Business Address ____________________________________________________ Telephone ____________________
Birth Date _________________________ SS # ____________________________ Occupation ___________________
(Must be 18 to register)
Have you had in the last 2 years
Do you:
Yes
No 1.
Chronic or recurrent illness?
Yes
No 11. Have any allergies?
(Diabetes, Asthma, Seizures ...)
Yes
No 2.
Any hospitalizations?
Yes
No 12. Have any problems with heart/blood pressure.
Yes
No 3.
Any surgery (Except tonsils)?
Yes
No 13. Has anyone in your family ever fainted during exercise?
Yes
No 4.
Any injuries that prohibited your participation in sports?
Yes
No 14. Take any medicine? List _________________________
Yes
No 5.
Dizziness or frequent headaches?
Yes
No 15. Wear glasses ___, contact lenses ___, dental appliances___?
Yes
No 6.
Concussion/knocked out?
Yes
No 16. Have any organs missing (eye, kidney, testicle, etc.)?
Yes
No 7.
Knee, ankle, or neck injuries?
Yes
No 17. Has it been longer than 10 years since your last tetanus
shot?
Yes
No 8.
Broken bone or dislocation?
Yes
No. 18. Have you ever been told not to participate in any sport?
Yes
No 9.
Heat exhaustion/sun stroke?
Yes
No 19. Do you know of any reason you should not participate in
Yes
No 10. Fainting or passing out?
sports?
Yes
No. 20. Have a sudden death history in your family?
PLEASE EXPLAIN ANY “YES” ANSWERS OR ANY OTHER
Yes
No. 21. Have a family history of heart attack before age 50?
ADDITIONAL CONCERNS.
Yes
No. 22. Develop coughing, wheezing, or unusual shortness of
breath when you exercise?
I also give my consent for the physician in attendance and the appropriate medical staff to give treatment at any athletic event for any injury.
SIGNATURE OF OFFICIAL ______________________________________________________________________DATE_______/_______/_______
PHYSICAL EXAM
Height ______________________ Weight _____________________ Pulse ______________________ Blood Pressure ______________________
Visual acuity: Uncorrected ________/_________; Corrected ________/________; Pupils equal diameter: Y
N
HEENT - acceptable
Y
N
Cardiovascular:
Abdomen:
Carotid Bruits
Y
N
Murmur
Y
N
Masses
Y
N
Respiratory:
Irregularities
Y
N
Organomegaly
Y
N
Symmetrical breath sounds Y
N
Murmur with Valsalva
Y
N
Genitourinary (males only)
Wheezes
Y
N
Musculoskeletal (Note any abnormalities) Y
N
Inguinal hernia
Y
N
Peripheral pulses equal
Y
N
RECOMMENDATION _______________________________ LIMITED APPROVAL FOR SPECIFIC SPORT (list) ________________________________
Physician Signature ________________________________________________________________ Date ____________________________________
MD / DO / DC / ARNP / PA-C
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