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Boston Mountain Rural Health Inc.934 N. Gaskill Street, Huntsville, AR 72740Date___________ Patient Name ____________________________ Date of Birth ___________(Circle One) Male or Female Grade _____________ Phone __________________Sports you participate in: ________________________________________________________Parent(s)/Guardian(s) ___________________________________________________________Address: ______________________________________________________________________ Street or P.O. Box City State Zip CodePast Medical History Circle “Yes” or “No”Have you had or do you have? Females OnlySurgery Yes NoAge when first menstrual periodDizziness Yes Nobegan: ____________________Chest Pain Yes NoDate of your last menstrual period:Heart MurmurYes No_______________________Racing Heart or Skipped Beats Yes NoExcessive flow? Yes NoAsthma / Wheezing Yes NoSpotting between periods? Yes NoSeizures Yes NoMuscle Cramps Yes NoEye Problems Yes NoAllergies / Swelling or reactions to insect stings or other substances? Yes NoHave you ever been hospitalized or gone to the ER? Yes NoHave you ever had a head injury, been knocked out or unconscious? Yes NoDo you tire more quickly than your friends during exercise? Yes NoDo you have trouble breathing or coughing during or after activities? Yes NoDo you use any special equipment? (Braces, knee pads, neck roll, etc) Yes NoHave you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of any bones or joints? Yes No (If so, circle the area below in which it occurred) Head Shoulder Thigh Neck Elbow Knee Chest Forearm Back Wrist Ankle Hip Hand Foot Shin/Calf Other_________________When was your last Tetanus shot?______________(Date) Measles Immunization?______________(Date)Do you have any medical problems? Yes No If yes, please explain: __________________________________________________________________________________________________________________Are you taking any medications or pills? Yes NoI hereby state that, to the best of my knowledge, the answers above are correct and complete. ______________________________ _______________________________ Signature of Athlete Signature of Parent/Guardian*********************************************************************************************HEENT: NL_______ABNL___________ NECK: NL_______ABNL__________CHEST: NL_______ABNL___________ ABD: NL_______ABNL__________G.U. NL_______ABNL___________ EXT: NL_______ABNL__________ASSESSMENT: HT: ___________ WT ___________ VISION(L)__________ (R)___________COMMENTS: B/P______________ __________________________________ M.D. ................
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