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?

Yes

No

22.

23.

Comments:_______________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

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

Date

Medical-Physical Form for Doctor.pdf

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