Mississippi Sports Medicine Athletics Physical Form – Fill Out and Use This PDF

The Mississippi Sports Medicine Athletics Physical Form is a critical document required by the University of Mississippi Medical Center/University Sports Medicine to assess the health and fitness of individuals participating in athletic activities. It comprehensively covers personal details, family and personal medical history, and an orthopedic history to ensure the safety and readiness of the athlete. For a smooth and secure participation in sports activities, it is important to accurately complete and submit this form. Click the button below to start filling out your form.

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Mississippi Sports Medicine Athletics Physical Form PDF Details

Embarking on a journey through the Mississippi Sports Medicine Athletics Physical form unveils a comprehensive process designed to ensure the safety and readiness of young athletes for participation in sports activities. Created by the University of Mississippi Medical Center/University Sports Medicine, this detailed document seeks printed inputs about personal and family medical history, alongside a meticulous record of orthopedic and general medical history, which is crucial in assessing the athlete's fitness level. It highlights the importance of disclosing conditions such as heart diseases, diabetes, or any orthopedic injuries that might affect the athlete's performance or well-being. Furthermore, the form shed light on the athlete's surgical history, current medications, and allergies, ensuring a holistic view of the athlete's health. The waiver form section underscores the legalities, offering protection to the medical professionals involved under Mississippi law, while the physical examination section, reserved for physicians, delves into specifics of the athlete's physical condition through a series of checks on various body parts, including spine, neck, and cardiovascular health, ensuring a thorough review. The form, therefore, serves as a critical tool in bridging the gap between a young athlete's health safety and their zeal for sporting excellence.

Question	Answer
Form Name	Mississippi Sports Medicine Athletics Physical Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	sports physical form, mississippi athletic form, mississippi physical form printable, mississippi sports physical form form

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DO NOT FOLD FORM

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER/UNIVERSITY SPORTS MEDICINE

ATHLETIC PARTICIPATION FORM

Please Print

Name __________________________________________________________________________________ Date ____________________________

School _______________________________________________________ Grade ___________ Sport(s) __________________________________

Sex: M F Date of Birth ______________________________ S.S.N. __________________________________________________ Age ________

Parent/Guardian Name __________________________________________________________________ Work Phone ________________________

Address _____________________________________________________________________________ Home Phone ________________________

Family Physician _______________________________________________________________________ Work Phone ________________________

			FAMILY MEDICAL HISTORY
			Has any member of your family under age 50 had these conditions?
Yes	No	Condition	Whom
		Heart Attack	___________________________________________________________________________
		Sudden Death	___________________________________________________________________________
		Stroke	___________________________________________________________________________
		Heart Disease / High Blood Pressure ___________________________________________________________________________
		Diabetes	___________________________________________________________________________
		Sickle Cell Anemia	___________________________________________________________________________
		Arthritis	___________________________________________________________________________
		Epilepsy	___________________________________________________________________________
		Kidney Disease	___________________________________________________________________________
			ATHLETE’S ORTHOPAEDIC HISTORY
			Has the athlete had any of the following injuries?
Yes	No	Condition	Date	Yes	No	Condition	Date
		Shoulder L / R	_____________________			Neck Injury / Stinger	____________________
		Elbow L / R	_____________________			Arm / Wrist / Hand L / R	____________________
		Hip	_____________________			Back	____________________
		Knee L / R	_____________________			Thigh L / R	____________________
		Chronic Shin Splints L / R	_____________________			Lower Leg L / R	____________________
		Foot L / R	_____________________			Ankle L / R	____________________
		Pinched Nerve	_____________________			Severe Muscle Strain	____________________
						Chest	____________________

Previous Surgeries: ________________________________________________________________________________________________________

ATHLETE’S MEDICAL HISTORY

Has the athlete had any of these conditions?
Yes	No	Condition	Yes	No	Condition	Yes	No	Condition
		Heart Murmur			Organ Loss			Overnight in hospital
		Seizures			Shortness of breath / coughing			Hernia
		Kidney Disease			during exercise			Rapid weight loss / gain
		Irregular Pulse			Chest Pain/Tightness			Take supplements / vitamins
		Single Testicle			Loss of consciousness/"Knocked out"			Heat related problems
		High Blood Pressure			Heart Disease			Menstrual irregularities
		Dizzy / Fainting			Diabetes			Recent Mononucleosis /
		Head Injury / Concussion			Liver Disease			Enlarged Spleen
		Asthma			Tuberculosis

 Have you had any serious medical illness/injury since your last sports physical? _____________________________________________

 Are you currently taking any prescription or non prescription (over the counter) medicaitons? ___________________________________

 Surgery - What Type? ___________________________________________________________________________________________

 Allergies (Food, Drugs) __________________________________________________________________________________________

Date of last Tetanus Immunization ____________________________________________________________________________________________

To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals provid- ing services may be immune from liability under Mississippi Law.

WAIVER FORM

This waiver, executed this ________ day of ___________________, 20____, by ______________________________________________ , M.D.

and ________________________________________, patient, is executed in compliance with Mississippi law, with the full understanding that if a phy-

sician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.

__________________________________________________					_________________________________________________________________
Signature of Patient					Typed or Printed Name of Physician
__________________________________________________					_________________________________________________________________
Signature of Parent/Guardian (Not required if patient is over 18 yrs old.)					Signature of Physician
			INFORMATION BELOW TO BE FILLED OUT BY PHYSICIAN ONLY
Height ______________________			Weight ____________________ Blood Pressure __________________ Pulse ____________________________
ORTHOPAEDIC EXAM				GENERAL MEDICAL EXAM
		Norm	Abnl			Norm	Abnl		Norm	Abnl
I.	Spine / Neck	________	________	ENT		________	________	Lungs	________	________
	Cervical	________	________	Heart		________	________	Abdomen	________	________
	Thoracic	________	________	Skin		________	________	Hernia (if Needed) ________		________
	Lumbar	________	________	General Health Comments ____________________________________________________
II.	Upper Extremity	________	________	__________________________________________________________________________
	Shoulder	________	________	__________________________________________________________________________
	Elbow	________	________	FLEXIBILITY		LEFT	RIGHT	FLEXIBILITY	LEFT	RIGHT
	Wrist	________	________	Neck		________	________	Shoulders	_________	________
	Hand / Fingers	________	________	Hips		________	________	Quadriceps	________	________
III.	Lower Extremity	________	________	Hamstrings		________	________	Achilles	________	________
	Hip	________	________	Back Ext / Flex		________	________
	Knee	________	________	Comments _________________________________________________________________
	Ankle	________	________	__________________________________________________________________________
	Feet	________	________	__________________________________________________________________________

Other Comments __________________________________________________________________________________________________________

OPTIONAL EXAMS
DENTAL	VISION L ________ R ________
Comments ___________________________________________	Comments: ____________________________________________________
____________________________________________________	_____________________________________________________________

Comments _______________________________________________________________________________________________________________

[	]	From this limited screening I see no reason why this student cannot participate in athletics
[	]	Student needs further evaluation as described

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Filling out part 1 in mississippi physical form printable

2. Soon after completing the last section, go to the subsequent step and fill in the essential particulars in all these blank fields - Yes No Condition Date Hip, Date, Condition Neck Injury Stinger Arm, Yes No, ATHLETES MEDICAL HISTORY, Shortness of breath coughing, Seizures Kidney Disease Irregular, Yes No Condition Organ Loss, Has the athlete had any of these, Overnight in hospital Hernia, Yes No Condition, Recent Mononucleosis Enlarged, Loss of consciousnessKnocked out, Liver Disease Tuberculosis, and Asthma.

Part no. 2 in completing mississippi physical form printable

3. This next segment focuses on INFORMATION BELOW TO BE FILLED OUT, Abnl, Abnl, Norm, Abnl, Norm, GENERAL MEDICAL EXAM Norm, Shoulder Elbow Wrist Hand Fingers, Spine Neck Cervical Thoracic, Lungs Abdomen Hernia if Needed, Height Weight Blood Pressure, FLEXIBILITY Shoulders Quadriceps, Hip Knee Ankle Feet, LEFT, and RIGHT - fill out each of these blank fields.

Stage # 3 of completing mississippi physical form printable

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Mississippi Sports Medicine Athletics Physical Form – Fill Out and Use This PDF

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