Fulton County Student Preparticipation Medical History / Physical Examination Form Page 2
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Record the dates of your most recent immunizations (shots) for:
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FEMALES ONLY
When was your first menstrual period?_________________________
Tetanus____________________________________
When was your most recent menstrual period?__________________
Measles ___________________________________
How much time do you usually have from the start of one period to
the start of another? ___________
Hepatitis B_________________________________
How many period have you had in the last year?________________
Chicken Pox _______________________________
What was the longest time between periods in the last year? ________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Athlete:
Signature of Parent/Guardian:
Date:
Use these spaces to record information from “YES” answers from the Medical Questions section.
Item #
Item #
Item #
Item #
Item #
The following part is to be completed by the examining physician for the preparticipation physical examination
Patient’s Name: _____________________________________________________ __________________ _____________________________DOB: ______________________
Height: ___________
Weight: ____________
Pulse:__________
BP: ___________
Vision: R/20 ______L20/_______
Corrected vision:
Yes / No
Pupils: Equal / Unequal
% body fat (optional) _______
Medical
Normal
Abnormal Findings
Initials*
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Musculoskeletal
Neck
Back
Shoulder / Arm
Elbow / Forearm
Wrist / Hand
Hip (thigh)
Knee
Leg / Ankle
Foot
Stationed-based examination only
*
Physician’s clearance to participate in interscholastic athletic practices and competitions.
Physician’s clearance to participate in interscholastic athletic practices and competitions after completing evaluation/rehabilitation for:
______________________________________________________________________________________________________________________________________.
Not cleared to participate in interscholastic athletic practices and competitions for : ___________________________Reason: ______________________
Recommendations: ________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician’s Name: ___________________________________________________________________ Office Telephone: _________________________________
Address: ________________________________________________________City: _________________________ State:________________ ZIP: ____________
Physician’s Signature: ______________________________________________________________ Date: __________________________________________
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