Sports Physical Examination Form

Player Name:   Age:    Date: 
Medicines:       Allergies: 

Health History  (To be completed by parent or guardian; answer Yes or No only)

Medical Questions for Parents

1.  Family history of sudden death before age 50? 
2.  Dizziness/fainting/chest pain with exercise?
3.  Heart murmur/heart condition?
4.  High Blood Pressure?
5.  Bone or joint injury (especially back or hips)?
6.  Sprain/dislocation?
7.  Serious head or spine trauma/repeated concussions/surgery on head or back?
8.  Detached retina?
9.  Known current illness/infection?
10. Uncontrolled asthma?
11. Uncontrolled seizures?
12. Recurrent skin disorders (boils, impetigo)?
13. Loss or serious impairment of a paired organ (kidney, eye, lung, testes)?
14. Known liver/spleen/kidney enlargement/mononucleosis/hepatitis?

                                                                        ____________________________          ___________
                                                                                  Signature of Parent                            Date
Physical Exam  (To be completed by physician)

Blood Pressure   Dentition  
Lungs   Heart  
Murmur?   Change with Valsalva?  
Abdomen - Organ Enlargement?   Testes  
Musculoskeletal   Skin  

Sports Participation Approved                      YES       NO

Return to Forms                                                ____________________________         ___________
                                                                                  Signature of Physician                        Date