PHYSICAL EXAMINATION FORM FOR ATHLETIC PARTICIPATION
PLEASE BRING THIS FORM TO
YOUR PHYSICIAN IF A PHYSICIAN IS NEEDED.
Name:
____________________________
___________________________ Date: ___ / ___ / ___
(Last) (First)
DOB: ___/___/___ Age: ________ Grade: _____ Height:
__________ Weight: ________
B/P: _____/_____ AP: _____
Temp: _____ RR: ________
Any Allergies: __________ List: _______________________________________________________
Date of Last Tetanus Immunization: ___/___/___ Date
of Last MMR: ___/___/___
Do you have any impaired function
of any impaired organ? (Eye, Lung, Kidney, Testes, Ovary)
List:
_______________________________________________________________________________
Have you ever passed out or nearly
passed out during or after exercise? ________________________
Have you ever had discomfort, pain
or pressure in your chest during exercise? ____________________
Does your heart ever race or skip
during exercise? ___________________________________________
Has your doctor ever told you that
you have high blood pressure/high cholesterol, a heart murmur or a heart
infection? ___________________________________________________
Has your doctor ever ordered a
test for your heart (i.e. electrocardiography, echocardiography) _________
Has anyone in your family died for
no apparent reason? ________________________________________
Has anyone in your family had a
heart attack? ________________________________________________
Does anyone in your family have a
heart problem? _____________________________________________
Has anyone in your family died of
heart problems or sudden death before 50 years of age? _____________
Does anyone in your family have
Marfam Syndrome? _______________________________
Were you previously taking
medication? ______ Are you currently
taking any medications? _______
What are you current medications?
_________________________ Dose: ____ # per day: ____ Diagnosis (reason)
_____________________
_________________________ Dose: ____ # per day: ____ Diagnosis (reason)
_____________________
If more please list:
______________________________________________________________________
Any illnesses/hospitalization? ________ List & Date:
__________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------
HEENT:
________________ Cardiac:
____________ Pulmonary: ____________ Hernia: _____________
Scoliosis Screen:
PASS __________ FAIL _________
Comments:
__________________________________________________________________________
Full participation in SPORTS, including competitive (please
circle one): YES NO
Full participation in ALL school activities (please circle
one): YES NO