Sports Physical Form
Name: ______________________________________ Gender: M F Date of Birth: ___/___/___
Father’s Name: _________________________ Daytime phone, pager, cell phone: _______________________
Mother’s Name: ________________________ Daytime, phone, pager, cell phone: _______________________
Street address: _____________________________________________________________________________
City: _________________ State: _______ Zip Code: __________ Home phone: ________________________
Alternate Emergency Contact Person: ______________________ Daytime phone: _______________________
Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc.: ______________________
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Medical History:
Athletes and parents: 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, |
YES |
NO |
Don’t Know |
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uncle) died suddenly before age 50? |
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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 |
YES |
NO |
Don’t Know |
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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 |
YES |
NO |
Don’t Know |
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because of illness, or has the athlete had a medical illness diagnosed that has not been |
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|
|
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resolved in the past year? |
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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.
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PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN
Height __________ |
Weight __________ |
Pulse __________ |
Blood Pressure __________ |
Vision: R _____ / _____ uncorrected R _____ / _____ corrected |
L _____ / _____ uncorrected L _____ / _____ corrected |
1.Eyes
2.Ears, Nose, Throat
3.Mouth & Teeth
4.Neck
5.Cardiovascular
6.Chest & Lungs
7.Abdomen
8.Skin
9.Genitalia-Hernia (male)
10.Muskuloskeletal: ROM, strength, etc.
a.neck
b.spine
c.shoulders
d.arms/ hands
e.hips
f.thighs
g.knees
h.ankles
i.feet
11.Neuromuscular
Please Print/ Stamp
Physician’s Name ___________________________________________________________________________________
Street Address _____________________________________________________________________________________
City, State, Zip Code ________________________________________________________________________________
Telephone _________________________________________________________________________________________
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. (Doctor of Chiropractic Medicine is not satisfactory.)
Physician Signature __________________________________________________________ Date __________________
PARTICIPATION RESTRICTIONS: _________________________________________________________________
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