Pre-participation History and Physical Examination Form by umsymums38


									                          Hazelwood School District - Hazelwood West High School
                       Pre-participation History and Physical Examination Form
                                           For Participation in Athletics

Name: ______________________________________ Birth Date _____/____/________
Address: ___________________________________ City: __________________ Zip: ________
Phone: (____)______________________ Current Grade level in School: _________
Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability.

Physician: Please review with the athlete details of any positive answers.

YES          NO         Don’t Know
___          ___         ______ 1) Have you had any illness/injury recently?
___          ___         ______ 2) Have you had a medical problem, illness/injury since your last exam?
___          ___         ______ 3) Do you have any chronic or recurrent illness?
___          ___         ______ 4) Have you ever been Hospitalized or had surgery?
___          ___         ______ 5) Do you take any prescribed medication, herbs or natural supplements?
___          ___         ______ 6) Do you have any organ missing other than tonsils (appendix, kidney)?
___          ___         ______ 7) Do you have any skin problems (Ringworm, impetigo, herpes, rashes)?
___          ___         ______ 8) Any seasonal allergies or reactions to other factors (bees, food)?
___          ___         ______ 9) Have you ever had prior limitations from physical activity or sports?
___          ___         _____ 10) Do you tire easily or quickly compared to your friends during exercise?
___          ___         _____ 11) Do you have asthma?
___          ___         _____ 12) Ever had chest pain, dizziness, or fainting, during or after exercise?
___          ___         _____ 13) Has the athlete ever had problems with blood pressure or heart?
___          ___         _____ 14) Does the athlete wheeze, or have trouble breathing with exercise?
___          ___         _____ 15) Are there any close relatives that died before age 50?
___          ___         _____ 16) Has the athlete ever suffered from heat exhaustion, stroke or heat cramps?
___          ___         _____ 17) Do you wear eyeglasses, contact lens, or protective eyewear? __________________
___          ___         _____ 18) Have you had any problems with your vision?
___          ___         _____ 19) Do you feel you are in good health?
___          ___         _____ 20) Have you had a broken bone (Fracture)?
___          ___         _____ 21) Have you ever had a severe sprained, “twisted”, joint injury?
___          ___         _____ 22) Have you ever had a head injury/concussion?
                                      How many times have you had a concussion? ______
                                      Did you suffer any memory loss or coordination dysfunction? ___________________
___           ___        _____ 23) Do you wear any dental appliance such as braces, bridges, etc?
___           ___        _____ 24) Have you ever suffered a neck injury?
___           ___        _____ 25) Do you have any known physical problems/illness?
___           ___        _____ 26) Do you need to wear any protective equipment for competition?
                   Females only 27) Have you had any serious/significant menstrual problems? ____________________
Please explain “YES” answers in space below.

Parent/Guardian’s Statement:
         I have reviewed and answered the questions above to the best of my ability. My child and I understand
and accept that there are risks of serious injury and death in any sport, including the one(s) in which my child has
chosen to participate. I hereby give permission for my child to participate in sports/activities.
I hereby authorize emergency medical treatment and /or transportation to is medical facility for any injury or illness
deemed urgently necessary by a registered athletic trainer, coach, or medical practitioner.
I understand that this sports Pre-Participation physical examination is not designed nor intended to substitute for
any recommended regular comprehensive health assessment.
         I also state that my child is covered by an accident and hospitalization policy, which includes coverage
resulting from injuries sustained while actively participating in supervised athletic practice or game.

Signed: ____________________________________ Date: ______________ Work phone             ______
               Parent/Guardian                                    Home phone___________________

Emergency contact: _____________________________________________ Phone: ________________

Relationship: _______________________________________________
Physical Examination for Athletics                                  NOTE: History & Consent Must be Completed Prior to Physical Examination

                                                          Please type or print

Student’s Name __________________________________________________                                       Birth Date _______________
                    Last                              First                 Middle Initial

Height __________ Weight __________                % Body Fat (optional) __________ Pulse ___________ BP ___________

Vision: R 20/_____ L 20/_____              Corrected:     Y    N        Pupils:      Equal       Unequal

     MEDICAL                                      Normal                         Abnormal Findings                            Initials
Lymph Nodes
Genitalia (males only)


         Cleared after completing evaluation/rehabilitation for: _________________________________
         Not Cleared for ____________________ Reason: ____________________________________
I certify that I have, on this date, examined this student and that, on the basis of the examination requested by the school authorities
and the student’s medical history as furnished to me, I have found no reason which would make it medically inadvisable for this
student to compete in supervised athletic activities. (Note exceptions above).
Physician’s Name, Address, and Phone (stamp or print)
_________________________________________                        _______________________________________ _________
_________________________________________                                        Examiner’s Signature                            Date

If the Physician’s Assistant (P.A.) or Advanced Nurse Practitioner (A.N.P.) performed the exam, name and address of
collaborating physician or physician group:

_________________________________________                      _______________________________________                       _________
_________________________________________                                         Examiner’s Signature                           Date

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