Fulton County School Physical Form PDF Details

If your child is starting school in Fulton County, Georgia, you'll need to complete a physical form. Here's everything you need to know about the process. The form must be completed and signed by a doctor within one year of the first day of school. You can find the form on the Fulton County School website. There is a $20 fee for physicals done at FCPS facilities. If your child's physical is done at an off-campus location, there may be a different fee structure. Be sure to ask your doctor if they participate in Fulton County's vision and hearing screening program- both screenings are required for students entering Kindergarten through 7th grade. Completed forms can be returned to your neighborhood school or any FCPS Student Services center. Be sure to submit your child's form as soon as possible, as slots fill up quickly!

QuestionAnswer
Form NameFulton County School Physical Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmononucleosis, fulton county school medical forms, PREPARTICIPATION, L20

Form Preview Example

FULTON COUNTY STUDENT PREPARTICIPATION MEDICAL HISTORY / PHYSICAL EXAMINATION FORM

This form is to be completed by the Parent/Guardian/Student and returned to the coach prior to the first practice session.

Student Name: _________________________________________________ Male __ / Female __ DOB: _____________________

(Last Name)

(First Name)

(MI)

 

 

 

(Month)

(Day)

(Year)

Address:________________________________________________________________

Home Tel, #: __________________

(# and Street Name)

(City)

(State)

(Zip Code)

 

 

 

 

 

Emergency Tel. # ________________Cellular Tel. #:________________ Grade this school year:

6

7

8

 

Name(s) of parent(s) /guardian(s) you live with: _________________________________________________________.

In Case of Emergency Contact: _____________________Relationship: _______________ Tel. #: ________________________

Personal Physician’s Name: ______________________________________________ Tel. #: ____________________________

Explain “YES” answers in the item spaces provided on next page. Circle #s to questions that you do not know the answers.

#

MEDICAL QUESTION

YES

NO

#

 

MEDICAL QUESTION

 

 

YES

NO

1

Have you had a medical illness or injury since your

 

 

24

Do you have frequent or severe headaches?

 

 

 

 

 

last check up or sports physical?

 

 

 

 

 

 

 

 

 

 

 

2

Have you ever been hospitalized overnight?

 

 

25

Have you ever had numbness or tingling in your

 

 

 

 

 

 

 

 

arms, hands, legs, or feet?

 

 

 

 

 

 

3

Have you ever had surgery?

 

 

26

Have you ever had a stinger, burner, or pinched

 

 

 

 

 

 

 

 

nerve?

 

 

 

 

 

 

 

4

Are you currently taking any prescription or non

 

 

27

Have you ever become ill from exercising in the

 

 

 

 

prescription (over- the-counter) medications or pills

 

 

 

heat?

 

 

 

 

 

 

 

 

or using an inhaler?

 

 

 

 

 

 

 

 

 

 

 

5

Have you ever taken any supplements or vitamins

 

 

28

Do you cough, wheeze, or have trouble breathing

 

 

 

 

to help you gain or lose weight or improve your

 

 

 

during or after activity?

 

 

 

 

 

 

 

performance?

 

 

 

 

 

 

 

 

 

 

 

6

Do you have any allergies (for example, to pollen,

 

 

29

Do you have asthma?

 

 

 

 

 

 

 

medicine, food, or stinging insects)?

 

 

 

 

 

 

 

 

 

 

 

7

Have you ever had a rash or hives develop during

 

 

30

Do you have seasonal allergies that require medical

 

 

 

 

or after exercise?

 

 

 

treatment?

 

 

 

 

 

 

 

8

Have you ever passed out during or after exercise?

 

 

31

Do you use any special protective or corrective

 

 

 

 

 

 

 

 

 

equipment or devices that aren't usually used for

 

 

 

 

 

 

 

 

your sport or position (for example, knee brace,

 

 

 

 

 

 

 

 

special neck roll, foot orthotics, retainer on your

 

 

 

 

 

 

 

 

teeth, hearing aid)?

 

 

 

 

 

 

9

Have you ever been dizzy during or after exercise?

 

 

32

Have you had any problems with your eyes or

 

 

 

 

 

 

 

 

 

vision?

 

 

 

 

 

 

 

10

Have you ever had chest pain during or after

 

 

33

DO you wear glasses, contact lenses, or protective

 

 

 

 

exercise?

 

 

 

eyewear?

 

 

 

 

 

 

 

11

Do you get tired more quickly than your friends do

 

 

34

Have you ever had a sprain, strain, or swelling after

 

 

 

 

during exercise?

 

 

 

injury?

 

 

 

 

 

 

 

12

Have you ever had racing of your heart or skipped

 

 

35

Have you broken or fractured any bones or

 

 

 

 

 

heartbeats?

 

 

 

dislocated any joints?

 

 

 

 

 

 

13

Have you had high blood pressure or high

 

 

36

Have you had any other problems with pain or

 

 

 

 

cholesterol?

 

 

 

swelling in muscles, tendons, bones, or joints?

 

 

 

 

14

Have you ever been told you have a heart murmur?

 

 

37

If yes to Question # 36 then

circle the part of the body below:

 

15

Has your family member or relative died of heart

 

 

 

 

 

 

 

 

 

 

 

 

problems or of sudden death before age 50?

 

 

 

Head

Elbow

Hip

Neck

Forearm

Thigh

16

Have you or any family member or relative been

 

 

 

Back

Wrist

Knee

Chest

Hand

Finger

 

diagnosed with diabetes before age 50?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

Have you had a severe viral infection (for example,

 

 

 

Shin/calf

Foot

Ankle

Shoulder

Upper arm

 

 

myocarditis or mononucleosis) within the last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month?

 

 

 

 

 

 

 

 

 

 

 

18

Has a physician ever denied or restricted your

 

 

 

 

 

 

 

 

 

 

 

 

participation in sports for any heart problem?

 

 

 

 

 

 

 

 

 

 

 

19

Do you have any current skin problems (for

 

 

 

 

 

 

 

 

 

 

 

 

example, itching, rashes, acne, warts, fungus, or

 

 

 

 

 

 

 

 

 

 

 

 

blisters)?

 

 

 

 

 

 

 

 

 

 

 

20

Have you ever had a head injury or concussion?

 

 

 

 

 

 

 

 

 

 

 

21

Have you ever been knocked out, become

 

 

38

Do you want to weigh more or less than you do

 

 

 

 

unconscious, or lost your memory?

 

 

 

now?

 

 

 

 

 

 

 

22

Have you ever had a seizure?

 

 

39

Do you lose weight regularly to meet weight

 

 

 

 

 

 

 

 

 

requirements for your sport?

 

 

 

 

 

23

Is there a history of Marfan’s Syndrome in your

 

 

40

Do you feel stressed out?

 

 

 

 

 

 

 

family?

 

 

 

 

 

 

 

 

 

 

 

41

Record the dates of your most recent immunizations (shots) for:

42

FEMALES ONLY

 

 

 

 

 

When was your first menstrual period?_________________________

 

Tetanus____________________________________

 

 

 

 

 

 

 

 

When was your most recent menstrual period?__________________

 

Measles ___________________________________

 

 

 

 

 

 

 

 

How much time do you usually have from the start of one period to

 

Hepatitis B_________________________________

 

 

the start of another? ___________

 

 

Chicken Pox _______________________________

 

 

How many period have you had in the last year?________________

 

 

 

 

What was the longest time between periods in the last year? ________

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

 

Signature of Athlete:

Signature of Parent/Guardian:

Date:

 

 

 

 

 

 

Use these spaces to record information from “YES” answers from the Medical Questions section.

Item #

Item #

Item #

Item #

Item #

The following part is to be completed by the examining physician for the preparticipation physical examination

Patient’s Name: _____________________________________________________ __________________ _____________________________DOB: ______________________

Height: ___________

Weight: ____________

Pulse:__________

BP: ___________

Vision: R/20 ______L20/_______

Corrected vision: Yes / No

 

Pupils: Equal / Unequal

% body fat (optional) _______

Medical

 

Normal

 

Abnormal Findings

 

 

Appearance

 

 

 

 

Eyes/Ears/Nose/Throat

 

 

 

 

Lymph Nodes

 

 

 

 

Heart

 

 

 

 

Pulses

 

 

 

 

Lungs

 

 

 

 

Abdomen

 

 

 

 

Genitalia (males only)

 

 

 

 

Skin

 

 

 

 

Musculoskeletal

 

 

 

 

Neck

 

 

 

 

Back

 

 

 

 

Shoulder / Arm

 

 

 

 

Elbow / Forearm

 

 

 

 

Wrist / Hand

 

 

 

 

Hip (thigh)

 

 

 

 

Knee

 

 

 

 

Leg / Ankle

 

 

 

 

Foot

 

 

 

 

Initials*

* Stationed-based examination only

Physician’s clearance to participate in interscholastic athletic practices and competitions.

Physician’s clearance to participate in interscholastic athletic practices and competitions after completing evaluation/rehabilitation for:

______________________________________________________________________________________________________________________________________.

Not cleared to participate in interscholastic athletic practices and competitions for : ___________________________Reason: ______________________

Recommendations: ________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Physician’s Name: ___________________________________________________________________ Office Telephone: _________________________________

Address: ________________________________________________________City: _________________________ State:________________ ZIP: ____________

Physician’s Signature: ______________________________________________________________ Date: __________________________________________

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The following part is to be, Patients Name DOB Height, and Signature of ParentGuardian inside fulton county physical form

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