Colfax High School - Athletic Medical History To be completed by parent prior to physical examination. Student Name______________________________________________ Today’s Date____________________ I hereby state that, to the best of my knowledge, my answers to the below questions are complete and correct. Signature of Parent/Guardian of Athlete:________________________________________________________
Please circle “Yes” or “No”
1.
Have you had a chronic or recurring illness?
Yes
No
2.
Have you ever been hospitalized?
Yes
No
3.
Have you ever had surgery other than tonsillectomy?
Yes
No
4.
Are you missing any organs? (Eye, kidney, etc.)
Yes
No
5.
Are you allergic to any medications?
Yes
No
6.
Do you or have you ever had any chest pain with exercise?
Yes
No
7.
Do you ever have dizziness or fainting with exercise?
Yes
No
8.
Do you have problems with blood pressure?
Yes
No
9.
Do you get frequent headaches or convulsions?
Yes
No
10.
Have you ever had a head injury or concussion?
Yes
No
a) Have you ever been knocked out, become unconscious or lost your memory?
Yes
No
b) Have you ever had a seizure?
Yes
No
c) Have you ever had numbness or tingling in your arms, hands, legs or feet?
Yes
No
d) Have you ever had a stinger, burner or pinched nerve?
Yes
No
11.
Have you ever had heat exhaustion, heat stroke or other problems with heat?
Yes
No
12.
Do you wear contact lenses?
Yes
No
13.
Are you currently taking any medications?
Yes
No
14.
Do you wear a brace or support for a specific activity?
Yes
No
15.
Do you have any history of injuries requiring MD treatment?
Yes
No
16.
Do you have any history of a neck injury?
Yes
No
17.
Is there any reason why this student should not participate in sports?
Yes
No
18.
Have you ever had a knee injury?
Yes
No
19.
Have you ever had an ankle injury?
Yes
No
20.
Have you ever had other serious joint injury?
Yes
No
21.
Has anyone in your family died of heart problems or sudden death before the age of 40? Had a heart attack?
Yes
No
Do you have asthma?
Yes
No
a) Do you cough, wheeze or have trouble breathing?
Yes
No
b) Do you have seasonal allergies that require medical treatment?
Yes
No
Have you ever had a sprain, strain or swelling after an injury?
Colfax High School - Physical Exam Sheet - To be completed by your Doctor. All participating students in athletics are required to have a physical examination for their protection and also for the information of the underwriting accident insurance company. Please list any abnormalities in detail. This form must be completed by a private physician. Students Name:_____________________________________________________________________ Weight_____________ Height____________
Pulse________ Blood Pressure
Hearing: L-________/15 R-________/15
Vision: L-20/__________R-20/________________
Capable of unlimited physical activity?
Yes_____
No
Yes_____
No
In need of further evaluation: Physically fit to engage in sports? Name of Physician Signature of Physician
There was a problem previewing this document. Retrying... Download. Connect more ... Medical-Physical Form for Doctor.pdf. Medical-Physical Form for Doctor.
Jan 24, 2012 - AI|Form 990filers§_rereculredtecompletQSchedujg0 38 X. Form 990 (2011) ... c If âYeS." to line 5a or 5b, did the organization file Form 8886-T? .
Jan 24, 2012 - ... this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is ...... CONVIO , 11 5 0 1 DOMAIN DRIVE SUITE 2 0 0 ,. AUSTIN, TX 78758 WEBSITE HOSTING 138_, 278 .
KiwiSaver Statements. ⢠Shareholder Statements. Page 1 of 1. Authorisation form for organisations.pdf. Authorisation form for organisations.pdf. Open. Extract.
Phone: 215 249-3310 Fax: 215 249-9875. DUBLINBOROUGH.ORG. Please mail to the above address or drop off at the Borough Hall. APPLICANT INFORMATION. Name: Home Address: Home Telephone Number: Cell Phone Number: Number of years residing in Dublin Boroug
Registration Form for Regional Disability Studies Conference.pdf. Registration Form for Regional Disability Studies Conference.pdf. Open. Extract. Open with.
factors is key to the application of drought risk mitigation in local water .... Justin Sheffield and his Princeton group on droughts as part of her INTENSE ERC ...
Transcript of Records (Bachelor's Degree) if the applicant is interested in the MBE. X. Declaration and Signature. I hereby agree to comply with the rules on ...
Central Library. Allowed / Not allowed. 3 6 Whole. Day. Page 2 of 2. Application Form for Hiring Auditorium.pdf. Application Form for Hiring Auditorium.pdf. Open.
... facts stated here come out to be false, and then the Billabong High EPS International School's management has full right to. withdraw my scholarship privilege.
All students seeking financial assistance from University College Maastricht must complete this form. ... Number of dependent children whose tuition will be paid ...
Predicting hydrological drought risk in Europe using big data of natural and socio-economic factors. Key words hydrological drought risk, prediction, combining ...
Billing Division or Location: 1508319. A. Employee Information (Complete for ALL ... Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL ... for coverage for my dependents at a later date, and if a physical examination o
Page 1 of 2. PRANVEER SINGH INSTITUTE OF TECHNOLOGY MODEL UNITED NATION CONFERENCE' 2018. FEB 3â 4, 2018. INDIVIDUAL DELEGATE REGISTRATION FORM. DELEGATE NAME. DELEGATE'S SCHOOL/COLLEGE NAME & ADDRESS. (AS APPLICABLE). DELEGATE CONTACT NO.: DELEGAT
... Armstrong, Bent House, Tarset, Hexham. NE48 1LD. Telephone: 01434 240964. Page 1 of 1. Main menu. Displaying Entry form for website.pdf. Page 1 of 1.
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Medication ...
your choice of study program would affect your personal and ... Upon completion of my studies in Sweden, I intend to reside in Sweden or other. OECD- ...
Download. Connect more apps... Try one of the apps below to open or edit this item. CRCW HOA Form for Complaints.pdf. CRCW HOA Form for Complaints.pdf.
2. - âTools for developing, managing and analysing 'Big Data', to understand risk better, ... www.bafg.de/GRDC/EN/Home/homepage_node.html), International ...