Fill and Sign the Sports Physical Form 497331864

Sports Physical Form Name: ______________________________________________________________ Gender: [ ] Male [ ] Female Date of Birth: ___/___/___ Father’s Name: __________________________________________________________  Address _________________________________________________________  Daytime phone ___________________ Home Phone________________  Cell Phone ___________________ Pager _______________________ Mother’s Name ___________________________________________________  Address _________________________________________________________  Daytime phone ___________________ Home Phone________________  Cell Phone ___________________ Pager _______________________ Alternate Emergency Contact Person: ___________________________________________  Address _________________________________________________________  Daytime phone ___________________ Home Phone________________  Cell Phone ___________________ Pager _______________________ Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc.: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Medical History: This health record is a critical element in the determination of an athlete’s risk of injury in sports. Please take the time to read and answer all questions before seeing a physician for the athlete’s physical examination. 1. Has anyone in the athlete’s family (grandparents, mother, father, brother, sister, aunt, uncle) died suddenly before age 50?  [ ] YES [ ] NO [ ] Don’t Know 2. Has the athlete ever stopped exercising because of dizziness or passed out during exercise?  [ ] YES [ ] NO [ ] Don’t Know 3. Does the athlete have asthma (wheezing), hay fever, or coughing spells after exercise?  [ ] YES [ ] NO [ ] Don’t Know 4. Has the athlete ever had a broken bone, had to wear a cast, or had an injury to any joint?  [ ] YES [ ] NO [ ] Don’t Know 5. Does the athlete have a history of concussion (getting knocked out)?  [ ] YES [ ] NO [ ] Don’t Know 6. Has the athlete ever suffered a heat-related illness (heat stroke)?  [ ] YES [ ] NO [ ] Don’t Know 7. Does the athlete have a chronic illness or see a doctor regularly for any particular problem?  [ ] YES [ ] NO [ ] Don’t Know 8. Does the athlete take any medication(s)?  [ ] YES [ ] NO [ ] Don’t Know 9. Is the athlete allergic to any medications or bee stings?  [ ] YES [ ] NO [ ] Don’t Know 10. Does the athlete have only one of any paired organs? (Eyes, ears, kidneys, testicles, ovaries)  [ ] YES [ ] NO [ ] Don’t Know 11. Has the athlete had an injury in the last year that caused the athlete to miss 3 or more consecutive days of practice or competition?  [ ] YES [ ] NO [ ] Don’t Know 12. Has the athlete had surgery or been hospitalized in the past year?  [ ] YES [ ] NO [ ] Don’t Know 13. Has the athlete missed more than 5 consecutive days of participation in usual activities because of illness, or has the athlete had a medical illness diagnosed that has not been resolved in the past year?  [ ] YES [ ] NO [ ] Don’t Know 14. Are you, the athlete, worried about any problem or condition at this time?  [ ] YES [ ] NO [ ] Don’t Know Please give details on any “YES” answer from the above health history. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________ PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN Height __________ Weight __________ Pulse __________ Blood Pressure __________ Vision: R _____ / _____ uncorrected R _____ / _____ corrected L _____ / _____ uncorrected L _____ / _____ corrected Normal Abnormal Findings Initials 1. Eyes ______________ _________________________________ __________ 2. Ears ______________ _________________________________ __________ 3. Nose ______________ _________________________________ __________ 4. Throat ______________ _________________________________ __________ 5. Mouth ______________ _________________________________ __________ 6. Teeth ______________ _________________________________ __________ 7. Neck ______________ _________________________________ __________ 8. Heart ______________ _________________________________ __________ 9. Lungs ______________ _________________________________ __________ 10. Abdomen ____________ ________________________________ __________ 11. Skin ______________ _________________________________ __________ 12 Hernia ______________ _________________________________ __________ 13. Musculoskeletal: Range of Motion, strength, etc.  Neck ______________ _________________________________ __________  Spine ______________ _________________________________ __________  Shoulders___________ _________________________________ __________  Arms ______________ _________________________________ __________  Hands______________ _________________________________ __________  Hips ______________ _________________________________ __________  Thighs______________ _________________________________ __________  Knees______________ _________________________________ __________  Ankles______________ _________________________________ __________  Feet ______________ _________________________________ __________ 14. Neuromuscular______________ ______________________________ __________ Physician’s Name __________________________________________ Street Address _______________________________________________________________ City_________________ State _______________________ Zip Code _________________ I certify that I have examined this athlete and found him/her medically qualified to participate in sports. I also certify that I am a licensed medical physician, physician’s assistant, or family nurse practitioner. Physician Signature _________________________________________ Date __________________ PARTICIPATION RESTRICTIONS: _______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________