School Sports Physical Form

Part 1. Student Information (to be completed by student or parent)

Student's Name

Sex

M F

Age

Date of Birth

School

Grade in School

Sport(s)

Home Address

Home Phone

Name of Parent/Guardian

Person to contact in case of emergency

Relationship to Student

Home Phone

Work Phone

Cell Phone

City/State

Office Phone

Part 2. Medical History (to be completed by student or parent)

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

Yes No

If yes, please explain

Do you have an ongoing chronic illness?

Yes No

If yes, please explain

Have you even been hospitalized overnight?

Yes No

If yes, please explain

Have you ever had surgery?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you ever passed out during or after exercise?

Yes No

If yes, please explain

Have you ever been dizzy during or after exercise?

Yes No

If yes, please explain

Have you ever had chest pain during or after exercise?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you had highblood pressure or high cholesterol?

Yes No

If yes, please explain

Have you ever been told you have a heart murmur?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you ever had a head injury or concussion?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you ever had a seizure?

Yes No

If yes, please explain

Do you have a frequent or severe headaches?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Have you ever become ill from exercising in the heat?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Do you have asthma?

Yes No

If yes, please explain

Do you have seasonal allergies that require medical treatment?

Yes No

If yes, please explain

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?

Yes No

If yes, please explain

Have you had any problems with your eyes or vision?

Yes No

If yes, please explain

Do you wear glasses, contacts or protective eyewear?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Yes No

Explain checked items above

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

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Do you feel stressed out?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

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

Tetanus

Hepatitis 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?

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

Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse pratitioner)

Student's Name

Date of Birth

Height

Weight

% of Body fat

Optional only

Pulse

Blood Pressure

Temperature

Hearing

Right (P)

Right (F)

Visual Acuity Left 20/

Left (P)

Left (F)

Visual Acuity Right 20/

Corrected

Yes No

Pupils

Equal Unequal

Medical

Appearance (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Eyes/Ears/Nose/Throat (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Heart (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Pulses (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Finding

Initials*

Lungs (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Abdomen (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Genitalia (males only) (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Musculoskeletal

Neck (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Back (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Shoulder/Arm (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Elbow/Forearm (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Wrist/Hand (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Hip/Thigh (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Knee (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Leg/Ankle (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

Foot (* - station-based examination only)

Findings

Normal

Yes No

Abnormal Findings

Initials*

For Office Use Only