Athletic Medical History And Physical Form - The Covenant School

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ATHLETIC MEDICAL HISTORY and PHYSICAL FORM
THE COVENANT SCHOOL ▪ CHARLOTTESVILLE - VA
This form is for all NEW students, ALL football players
and returning students entering grades 7, 9, and 11.
Student Name: _____________________________________________________________
Birthdate: __________________
Grade: _______
Parents: Please complete this side of the form on your child’s behalf prior to the medical
examination, and
make a copy of each side for your personal file before returning the completed form to:
175 Hickory Street
Charlottesville, VA
22902
Attn: Dave Hart
The Covenant School ▪
YES
NO
IF ANSWERED “YES” - PLEASE EXPLAIN:
Have any members of your family, under age 50, had a heart attack? ____________________________________
Have you ever passed out while exercising?
____________________________________
Do you have a heart murmur?
____________________________________
Do you have high blood pressure?
____________________________________
Do you have any other heart problems?
____________________________________
Have you had, or do you have, asthma?
____________________________________
Do you have wheezing or chest tightness when you exercise?
____________________________________
Have you ever dislocated or broken a bone or joint?
____________________________________
Have you ever been knocked out or had a concussion?
____________________________________
Have you ever been under a physician’s care for a continuing medical problem? ____________________________
Have you ever stayed in the hospital overnight?
____________________________________
Have you ever had surgery?
____________________________________
Have you ever had any blood disorders, including sickle cell trait anemia, etc.? _____________________________
Are you taking any medication (including asthma medication)?
____________________________________
Do you wear glasses or contacts for athletic competition?
____________________________________
Do you have allergic reactions to medications, food, bee stings, etc.? ____________________________________
Do you wear braces or use a retainer?
____________________________________
Date of last tetanus immunization: ________________________________
(The reverse side must be completed by a physician)

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