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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download