Sports Physical
|Name: | |Sex: | |
| |Y / N | |Y / N |
|Has a doctor ever denied or restricted your participation in sports | |Have you ever had an injury involving a sprain, strain, or swelling? | |
|for any reason? | | | |
|Have you had a medical illness or injury since your last check-up or | |Have you broken or fractured any bones or dislocated any joints? | |
|sports physical? | | | |
|Do you have an on-going or chronic illness? | |Do you have a history of eye or vision problems? | |
|Have you ever been hospitalized overnight? | |Do you wear glasses, contacts, or protective eyewear? | |
|Have you ever had surgery? | |Have you ever had a seizure? | |
|Do you have any allergies? | |Have you ever had numbness or tingling in your arms, hands, legs, or | |
| | |feet? | |
|Have you had a rash or hives during or after exercise? | |Have you ever had a stinger, burner, or pinched nerve? | |
|Have you ever passed out during or after exercise? | |Do you have asthma? | |
|Have you ever been dizzy during or after exercise? | |Do you cough, wheeze, or have trouble breathing during or after | |
| | |activity? | |
|Have you ever had chest pain during or after exercise? | |Have you ever had a head injury or concussion? | |
|Do you get tired more quickly than your friends during exercise? | |Have you ever been knocked out, become unconscious, or lost your | |
| | |memory? | |
|Have you ever had a racing heart or skipped heartbeats? | |Do you have frequent or severe headaches? | |
|Have you had high blood pressure or high cholesterol? | |Do you need any special or corrective equipment that aren't usually | |
| | |used for your sport? | |
|Have you ever been told you have a heart murmur? | |Are you currently taking any prescription or non-prescription | |
| | |medications? | |
|Has any family member or relative died of heart problems or of sudden | |Have you ever taken any supplements or vitamins to help you gain or | |
|death before age 50? | |lose weight? | |
|Has a physician ever denied or restricted your participation in sports| |Have you ever taken any supplements or vitamins to improve your | |
|for any heart problems? | |performance? | |
|Have you had a viral infection within the last month? | |Do you want to weigh more or less than you do now? | |
|Do you have seasonal allergies that require medical treatment? | |Do you lose weight regularly to meet weight requirements for your | |
| | |sport? | |
|Do you have any current skin problems? | |Do you feel stressed out? | |
|Have you ever become ill from exercising in the heat? | |Have you ever been diagnosed with sickle cell anemia? | |
| | |Have you ever been diagnosed with sickle cell trait? | |
|Have you had any other problems with pain or swelling in the following muscles, tendons, bones, or joints? |
|Y / N | |Y / N | |Y / N | |Y / N | |
| |Neck | |Elbow | |Finger | |Shin / Calf |
| |
| |
|Females Only | | | |
| |Y / N |How many days do you usually have from the start of one period to the| |
|Have you ever had a menstrual period? | |start of another? | |
|How old were you when you started menstruation? | |How many periods have you had in the last 12 months? | |
|When did your most recent menstrual period begin? | |What was the longest time between periods in the last year? | |
_______________________________ _______________ _______________________________ _______________
Student Signature Date Parent/Guardian Signature Date
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