Sample Athletic Medical Record
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12015-2016
ANN ARBOR MIDDLE SCHOOL ATHLETIC MEDICAL RECORD
(This form MUST be turned into the main office BEFORE the student practices with any team. NO EXCEPTIONS)
Student Name
Grade:
Gender:
School:
6
7
8
M
F
Student Address
Date of Birth:
Age:
____-____-____
______
Month-day-year
Mother/Guardian Name
Home Phone
Mother Cell Phone
Father/Guardian Name
Home Phone
Father Cell Phone
Emergency Contact Name
Relationship to Student
Cell Phone
Emergency Contact Name
Relationship to Student
Cell Phone
Family Physician Name
Preferred Hospital
Health Insurance Company &
Policy Numbers:
Circle the appropriate numbers if this student has had any of the following:
1. Perforated ear drum
12. Heart surgery
23. Internal injuries
34. Head injuries
2. Draining ear
13. Pneumonia
24. Appendectomy
35. Undescended testicle
3. Ear surgery
14. Tuberculosis
25. Hernia
36. Operation on testicle
4. Mastoid surgery
15. Asthma
26. Hernia repair
37. Kidney trouble
5. Hearing loss
16. Chest pain
27. Neck injuries
38. Diabetes
6. Frequent sore throat
17. Short of breath
28. Shoulder injuries 39. Blood in urine
7. Convulsions
18. Punctured lung
29. Elbow injuries
40. Protein in urine
8. Rheumatic fever
19. Lung disease
30. Wrist injuries
41. Reaction to insect bites
9. Heart Disease
20. Hepatitis
31. Knee problem
42. Medications (list all)
10.Heart murmur
21. Infectious mono
32. Ankle problem
43. Broken bones (list all)
11.High blood pressure
22. Peptic ulcer
33. Back problem
___________________
Date of last tetanus shot:_______________
Does this student wear contact lenses? YES NO
PHYSICAL EXAMINATION (To be completed and signed by a PHYSICIAN ONLY)
ENT
Abdomen
Lower Extremities
B.P.
Hernias
Urinalysis
Heart
Genitalia
Blood
Lungs
Pilonidal
Protein
Upper Extremities
Back & Neck
Sugar
Chest
Other
Physical conditions or limitations of which athletic or medical personnel should be aware:
___________________________________________________________________________________________
Date ____________________ Physician’s Signature _______________________________________________
**Per M.H.S.A.A. Rule, NO LPN, RN Nurse or Chiropractor signatures can be accepted.
th
This physical must be dated after April 15th of previous school year. (after April, 15
2015)**
MUST TURN IN TO GRADE OFFICE
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