PHYSICAL EXAMINATION FORM FOR ATHLETIC PARTICIPATION

Name: ______________________ __________________ Date: ______/______/_______
(LAST) (FIRST)

DOB: _____/_____/_____ Age: _______ Grade: ______ Height: _____’_____”

Weight:__________ B/P: _____/_____ AP: _______ Temp: ________ RR: _______

Date of last tetanus Immunization: _____/_____/_____ Date of Last MMR: _____/_____/_____

Do You Have Any Impaired Function of Any Paired Organ? (1 Eye, Lung, Kidney, Testes, Ovary)

LIST: _________________________________________________________________

Have Any of Your Biological Family – Mother, Father, Brother (s), Sister (s), Die Suddenly at Age 59 or Less? ____________. If so, Who and On What Side of Family? _________________

Have You Ever Fainted? ______ What Were You Doing At The Time? ____________________

Were You Previously Taking Medication? ________ Are You Currently Taking Any Medications? _____

What Are Your Current Medications?

________________ Dose: __________ # per Day: __________ Diagnosis (Reason) __________________

(IF More Please List): ___________________________________________________________________

Any Allergies” __________________ List: __________________________________________________

Any Illnesses/Hospitalizations? __________________ List & Date: _______________________________

DATE: _____/_____/_______ Parent Signature: __________________________________

BOTTOM TO BE FILLED OUT BY PHYSICIAN

HEENT: _______ Cardiac: _______ Pulmonary: _______ Hernia:_______

Scoliosis Screen: PASS ________ FAIL ________

Comment (s) ___________________________________________________________________________

Full Participation in Sports Including Competitive: YES NO

Full Participation in ALL School Activities: YES NO

DATE: _____/_____/_______ Physician Signature: _______________________________