Farmington Public Schools Sports Physical Exam Form Page 2
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2SPORTS PARTICIPATION HEALTH RECORD
This evaluation is only to determine readiness for sports participation. It should not be used as a substitute for regular health
maintenance examinations. THIS SIDE MUST BE COMPLETED BY PARENT/GUARDIAN AND PRESENTED TO
PHYSICIAN AT THE TIME OF EXAM.
NAME: ________________________________ AGE: ________ SEX: ______ SCHOOL ________________________
ADDRESS: ___________________________________________ PHONE: ____________________ GRADE: ________
SPORTS BEING PLAYED (1) _______________________ (2) _________________________ (3) ____________________
Health Insurance Company: _____________________________________________ Policy Number: __________________
MEDICAL HISTORY
(To be completed by student and parent or guardian)
1. Do you have any allergies? (drugs, food, insect sting, etc.)
No
Yes If yes, list _______________________________________________________________________
2. Are you currently taking any drugs or medications including steroids or protein supplements? (Daily or occasionally?)
No
Yes If yes, list _______________________________________________________________________
3. Are you presently being treated for any condition by a physician other health care professional?
No
Yes If yes, list _______________________________________________________________________
4. Have you ever been advised by a doctor not to participate in any sport?
No
Yes If yes, list _______________________________________________________________________
5. Do you have any chronic conditions, disorders or diseases? Check those applicable or
none
_____ Asthma
_____ Bleeding Disorders
_____ Kawasaki’s disease
_____ Handicap (Describe:
_____ Diabetes
_____ Mononucleosis - YR _____
_____ Epilepsy (seizures)
_____ Hepatitis (liver disease)
_____ Hypertension (High blood pressure)
_____ Sickle Cell Anemia
Other
Please check where applicable if you have or have had any of the following:
YES
NO
YES
NO
Head injury, concussion or being unconscious
Eye injury or retinal detachment
If yes, how many times ____________
Blurred vision or vision in one eye only
Headaches more than once a week
Wear glasses or contact lenses
Lack of feeling or numbness in any part of the body
Hearing loss or impairment in one or both ears
Heat exhaustion or heat stroke
Tube in ears or a perforated eardrum
Difficulty running ½ mile without stopping
False teeth, caps or braces
Chest pain, dizziness or passing out during exercise
Nose bleed for no reason
Coughing, wheezing or gasping for breath with
Bruising easily or taking a long time to stop
exercise or cold weather
bleeding when cut
Smoke cigarettes or chew tobacco
Diarrhea more than once a week
Heart problems, murmur or arrhythmia
Black or bloody bowel movements (stools)
Family member with a heart attack under age 50
Kidney disease or dark, brown or bloody urine
Loss or gain of more than 10 lbs. in last year
Less than two kidneys or, in males, two testicles
Special diet for medical reasons
Lump(s) in arm pit or groin
For female participants:
Rash or skin problem
Absent or irregular monthly periods
Disabling cramps with your menstrual periods
Neck, spine or low injury or pain
Have you ever been hospitalized for medical or surgical reasons? ___ No ___ Yes
If yes, provide the following information:
REASON
YEAR
HOSPITAL
Please carefully list below any injury (nerve, muscle, bone or joint) that you have had which did not allow you to participate
in regular activity for a week or more?
INJURED AREA
YEAR
SIDE
TYPE
(Knee, hamstring, neck, shin, etc.)
(R.L.)
(Fracture, sprain, swelling, pinched nerve, etc)
YES
NO
STUDENT AND OR GUARDIAN: We hereby state that we have reviewed this medical history and found the information above
to be correct to the best of our knowledge.
_____________________________________ _______________ _________________________________________ ___________
Student Signature
Date
Parent or Guardian Signature
Date
Revised: 6/03
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