Sports Physical Doctor Forms

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Date of Exam ________________________
Name __________________________________________ Sex ____ Age___ Date of Birth _____________
Grade _______
Sport (s) _______________________________________________
Address ___________________________________________________ Phone ______________________
Personal Physician _______________________________________________________________________
In case of emergency, contact
Name ________________________________Relationship ____________ Phone (H) ________ (W) _________
Explain “Yes” answers below. Circle questions you don’t know the answers to.
Yes/No
Yes/No
1. Have you had a medical illness or injury since
___ ___
10. Do you use any special protective or corrective
___ ___
your last check up or sports physical?
equipment or devices that aren’t usually used for
Do you have any ongoing or chronic illness?
___ ___
your sport or position (for example, knee brace,
2. Have you ever been hospitalized overnight?
___ ___
special neck roll, foot orthotics, retainer on your
Have you ever had surgery?
___ ___
teeth, hearing aid)?
3. Are you currently taking any prescription or
11. Have you had any problems with your eyes or vision? ___ ___
___ ___
non prescription (over-the-counter) medications
Do you wear glasses, contacts, or protective eyewear?
___ ___
or pills or using an inhaler?
12. Have you ever had a sprain, or swelling after injury? ___ ___
Have you ever taken any supplements or vitamins
___ ___
Have you broken or fractured any bones or dislocated
___ ___
to help you gain or lose weight or improve your
any joints?
performance?
Have you had any other problems with pain or swelling
___ ___
4. Do you have any allergies (for example, to
___ ___
in muscles, tendons, bones, or joints?
pollen, medicine, food, or stinging insects)?
If yes, check appropriate item and explain below.
Have you ever had a rash or hives develop during
___ ___
Head
__
Elbow __
Hip
__
or after exercise?
Neck
__
Forearm __
Thigh
__
5. Have you ever passed out during or after exercise? ___ ___
Back
__
Wrist
__
Knee
__
Have you ever been dizzy during or after exercise?
___ ___
Chest
__
Hand
__
Shin/Calf __
Do you get tired more quickly than your friends do
___ ___
Shoulder
__
Finger __
Ankle
__
during exercise?
Upper Arm __
Foot
__
Have you ever had racing of your heart or skipped
___ ___
13. Do you want to weigh more or less than you do now? ___ ___
heartbeats?
Do you lose weight regularly to meet weight
___ ___
Have you had high blood pressure or high cholesterol? ___ ___
requirements for your sport?
Have you ever been told you have a heart murmur?
___ ___
14. Do you feel stressed out?
___ ___
15. Record the dates of your most recent immunizations
Has any family member or relative died of heart
___ ___
problems or of sudden death before age 50?
(shots) for:
Have you had a severe viral infection (for example,
Tetanus _________________
Measles ____________
myocarditis or mononucleosis) within the last month? ___ ___
Hepatitis B ______________
Chickenpox _________
Has a physician ever denied or restricted your
FEMALES ONLY:
16. When was your first menstrual period? _____________
participation in sports for any heart problems?
___ ___
6. Do you have any current skin problems (for
When was your most recent menstrual period? ___________
example, itching, rashes, acne, warts, fungus, blisters)? ___ ___
How much time do you usually have from the start of one
7. Have you ever had a head injury or concussion?
___ ___
period to the start of another? ________________________
Have you ever been knocked out, become
___ ___
How many periods have you had in the last year? ________
unconscious, or lost your memory?
What was the longest time between periods in the last year? ____
Have you ever had a seizure?
___ ___
Do you have frequent or severe headaches?
___ ___
Explain “Yes” answers here:
Have you ever had numbness or tingling in your
______________________________________________________
arms, hands, legs, or feet?
______________________________________________________
Have you ever had a stinger, burner, or pinched nerve? ___ ___
______________________________________________________
8. Have you ever become ill from exercising in the
___ ___
______________________________________________________
heat?
______________________________________________________
9. Do you cough, wheeze, or have trouble breathing
___ ___
______________________________________________________
during or after activity?
______________________________________________________
Do you have asthma?
___ ___
______________________________________________________
Do you have seasonal allergies that require
___ ___
______________________________________________________
medical treatment?
I herby state that, to the best of my knowledge, my answers to the above questions are complete and correct. I also give my permission
for my student to have a physical exam. (Parent/Guardian consent)
Signature of Athlete _____________________________________ Signature of Parent/Guardian _________________________ Date ___________

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