School Sports Physical Form

Student's Name:

Sex:
-MaleFemale

Age:

Date of Birth:

School:

Grade in School:

Sport(s):

Home Address

Home Phone:

Name of Parent/Guardian:

Email:

Person to contact in case of emergency:

Relationship to Student:

Home Phone:

Work Phone:

Cell Phone:

City/State:

Office Phone:

Have you had a medical illness or injury since you last check up or sport physical? -YesNo

Do you have an ongoing chronic illness? -YesNo

Have you even been hospitalized overnight? -YesNo

Have you ever had surgery? -YesNo

Are you currently taking any prescription or non-prescription (over-the-counter) medications or pills or using an inhaler? -YesNo

Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance? -YesNo

Do you have any allergies (for example, pollen, latex, medicine, food or stinging insects? -YesNo

Have you ever had a rash or hives develop during or after exercise? -YesNo

Have you ever passed out during or after exercise? -YesNo

Have you ever been dizzy during or after exercise? -YesNo

Have you ever had chest pain during or after exercise? -YesNo

Do you ever get tired more quickly than your friends do during or after exercise? -YesNo

Have you ever had racing of you heart or skipped heartbeats? -YesNo

Have you had highblood pressure or high cholesterol? -YesNo

Have you ever been told you have a heart murmur? -YesNo

Has any family member or relative died of heart problems or sudden death before age 50? -YesNo

Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month? -YesNo

Has a physician ever denied or restricted your participation in sports for any heart problems? -YesNo

Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, blisters or pressure sores? -YesNo

Have you ever had a head injury or concussion? -YesNo

Have you ever been knocked out, become unconscious or lost your memory? -YesNo

Have you ever had a seizure? -YesNo

Do you have a frequent or severe headaches? -YesNo

Have you ever had numbness or tingling in your arms, hands, legs or feet? -YesNo

Have you ever had a stinger, burner or pinched nerve? -YesNo

Have you ever become ill from exercising in the heat? -YesNo

Do you cough, wheeze or have trouble breathing during or after activity? -YesNo

Do you have asthma? -YesNo

Do you have seasonal allergies that require medical treatment? -YesNo

Do you use any special protective or corrective equipment or medical devices that aren't usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, shunt, retainer on your teeth or hearing aid? -YesNo

Have you had any problems with your eyes or vision? -YesNo

Do you wear glasses, contacts or protective eyewear? -YesNo

Have you ever had a sprain, strain, or swelling after injury? -YesNo

Have you broken or fractured any bones or dislocated any joints? -YesNo

Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? -YesNo

If yes, check appropriate blank and explain below:

Head
Neck
Back
Chest
Shoulder
Upper Arm

Elbow
Forearm
Wrist
Hand
Finger
Foot

Hip
Thigh
Knee
Shin/Calf
Ankle

Do you want to weigh more or less than you do now? -YesNo

Do you lose weight regularly to meet weight requirements for your sport? -YesNo

Do you feel stressed out? -YesNo

Have you ever been diagnosed with having the sickle cell trait? -YesNo

Record the dates of your most recent immunizations (shots) for:

Tetanus:

Hepatitus B:

Measles:

Chickenpox:

FEMALES ONLY (optional)

When was your first menstrual period?

When was your most recent menstrual period?

How much time do you usually have from the start of one period to the start of another?

How many periods have you had in the last year?

What was the longest time between periods in the last year?

Explain "Yes" answers here:

We hereby state to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida Statutes, and FHSAA By law 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assesssment, which may include diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.

Signature of Student:

Date:

Signature of Parent/Guardian:

Date:

Student's Name:

Date of Birth:

Height:

Weight:

% of Body fat (optional):

Pulse:

Blood Pressure:

Temperature:

HEARING

Right:
P F

Left:
P F

Visual Acuity Right 20/:

Visual Acuity Left 20/:

Corrected:
-YesNo

Pupils:
-EqualUnequal

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

Findings:

Normal:
-YesNo

Abnormal Findings:

Initials*:

I hereby certify that each information listed above was performed by myself or an individual under my supervision with the following conclusion(s):

Cleared without limitation:
-YesNo

Disability:
-YesNo

Diagnosis:

Precautions:
-YesNo

Not cleared for:
-YesNo

Reason:

Cleared after completing evaluation/rehabilitation for:
-YesNo

Referred to:
-YesNo

For:

Recommendations:

Name of Physician/Physician Assistant/Nurse Practitioner (print)

Date:

Address:

Signature of Physician/Physician Assistant/Nurse Practitioner:

I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):

Cleared without limitation:
-YesNo

Disability:
-YesNo

Diagnosis:

Precautions:
-YesNo

Not cleared for:
-YesNo

Reason:

Cleared after completing evaluation/rehabilitation for:
-YesYes

Recommendations:

Name of Physician (print):

Date:

Address:

Signature of Physician: