physical history form 2011

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					               Maine South Pre-Participation Physical History Form
Name______________________________ Address_________________________________________________________

Sex:__________ Age:__________ Date of Birth_______________________ School ID#____________________

Family Physician_____________________________________ Physican Phone Number___________________________

Parent or Guardian______________________________ Phone Number______________________________
Does your child need Special Medical equipment (i.e. inhaler, glucose tabs, epi-pen, etc.)___________________

                                                                      This section is to carefully completed by the student and his/her parent(s) or legal guardians(s)
                                                                   the day of the physical evaluation. The physician will not evaluate you if this form is not completed.

Circle all questions you don’t know the answer to.                                Yes        No                                                                             Yes   No
Are you currently taking any prescription or nonprescription                                            Is there anyone in your family who has asthma?
(over the counter) medicines?                                                                           Have you ever used an inhaler or taken asthma medicine?
Do you have any allergies to medicines, pollens,                                                        Were you born without or are you missing a kidney, an eye,
foods, or stinging insects?                                                                             a testicle, or any other organ?
Do you think you are in good health?                                                                    Have you had Infectious Mononucleosis (Mono) within
Have you ever passed out or nearly passed out during exercise?                                           the last month?
Have you ever passed out or nearly passed out after exercise?                                           Do you have any rashes, pressure sores, or other skin problems?
Have you ever had discomfort, pain, or pressure in                                                      Have you had a Herpes skin infection?
your chest during exercise?                                                                             Have you ever had a head injury or concussion?
Does your heart race or skip beats during exercise?                                                     Have you ever been hit in the head and been confused or
has a doctor ever told you that you have (circle)                                                       lost your memory?
High Blood Pressure                                 High Cholesterol                                    Have you ever had a seizure?
A Heart Murmur                                      A Heart Infection                                   Do you have headaches with exercise?
Has a doctor ever ordered a test for your heart?                                                        Have you ever had numbness, tingling, or weakness in your arms
Does anyone in your family have a heart problem?                                                         or legs after being hit or falling?
Has any family member or relative died of a heart problem or of                                         Have you been unable to move your arms or legs after
sudden death before age 50?                                                                             being hit or falling?
Does anyone in your family have Marfan Syndrome?                                                        When exercising in the heat, do you have severe muscle
Have you ever spent a night in the hospital?                                                            cramps or become ill?
Have you ever had surgery?                                                                              Has a doctor told you that you or someone in your family
Have you ever had a injury like a sprain, ligament tear, or tendonitis that                             has Sickle Cell Trait or Sickle Cell Disease?
caused you to miss a practice or game? If yes, circle the area injured.                                 Have you had any problems with your eyes or vision?
Neck Shoulder Elbow Wrist Hand Spine Hip Knee Ankle Foot                                                Do you wear glasses or contact lenses?
Have you had a fractured bone or dislocated joint? If yes, circle below.                                Do you wear protective eyewear, such as goggles or a faceshield?
Neck, Shoulder, Upper Arm, Elbow, Forearm, Wrist, Hand                                                  Are you happy with your weight?
Spine, Hip, Thigh, Knee, Lower leg, Ankle, Foot                                                         Are you trying to lose or gain weight?
Have you ever had a bone or joint injury that required x-rays, MRI, CT,                                 Has anyone recommended you change your weight or eating habits?
surgery, injections, physical therapy, a brace, or crutches?                                            Do you limit or carefully control what you eat?
If yes, circle below.                                                                                   Do you have any concerns that you would like to discuss
Neck, Shoulder, Upper Arm, Elbow, Forearm, Wrist, Hand                                                  with a doctor?
Spine, Hip, Thigh, Knee, Lower leg, Ankle, Foot                                                         Do you drink alcohol, take illicit drugs or smoke?
Have you ever had a stress fracture?
Have you been told that you have or have you had an x-ray for                                           Females Only
atlantoaxial (neck) instability?                                                                        Have you ever had a menstrual period?
Do you regularly use a brace or assistive device?                                                       How old were you when you had your first menstrual period?
Has a doctor ever told you that you have asthma?                                                        How many periods have you had in the last 12 months?

Do you have any problems with: (Circle All That Apply)

Skin                    Head                    Eyes                    Ears            Mouth/Throat                            Weight Control                       Neck
Lungs                     Abdomen                            Back               Urination                  Genitol                        Hips/Legs/Feet
Muscle                        Bone                   Mental                    Fatigue
                                   I/We hereby state, to the best of my/our knowledge, my/our answers are correct.
                                             I/We do hereby authorize a Pre-Participation Physical Exam.
Athletes Signature:_________________________ Parent or Guardian Signature:________________________ Date:_________

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