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

There was a problem previewing this document. Retrying... Download. Connect more ... Medical-Physical Form for Doctor.pdf. Medical-Physical Form for Doctor.

100KB Sizes 1 Downloads 230 Views

Recommend Documents

Form 990 - People for the American Way
Jan 24, 2012 - AI|Form 990filers§_rereculredtecompletQSchedujg0 38 X. Form 990 (2011) ... c If ”YeS." to line 5a or 5b, did the organization file Form 8886-T? .

Form 990 - People for the American Way
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 .

Authorisation form for organisations.pdf
KiwiSaver Statements. • Shareholder Statements. Page 1 of 1. Authorisation form for organisations.pdf. Authorisation form for organisations.pdf. Open. Extract.

Volunteer Application for Commissions Form 2015 interactive.pdf ...
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. Registration Form for Regional Disability Studies Conference.pdf. Open. Extract. Open with.

DREAM PROPOSAL FORM for OCTOBER 2015 INTAKE
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 ...

Application Form for SBEP Admission.pdf
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 ...

Form For-DUPLICATE MARKESHEET.pdf
Form For-DUPLICATE MARKESHEET.pdf. Form For-DUPLICATE MARKESHEET.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Form ...

Application Form for Hiring Auditorium.pdf
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.

application form for scholarship.pdf
... 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.

Application form for UCM Scholarship - Maastricht University
All students seeking financial assistance from University College Maastricht must complete this form. ... Number of dependent children whose tuition will be paid ...

DREAM PROPOSAL FORM for OCTOBER 2015 INTAKE
Predicting hydrological drought risk in Europe using big data of natural and socio-economic factors. Key words hydrological drought risk, prediction, combining ...

enrollment form for group insurance
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

Individual registration form for schools.pdf
Page 1 of 2. PRANVEER SINGH INSTITUTE OF TECHNOLOGY MODEL UNITED NATION CONFERENCE' 2018. FEB 3– 4, 2018. INDIVIDUAL DELEGATE REGISTRATION FORM. DELEGATE NAME. DELEGATE'S SCHOOL/COLLEGE NAME & ADDRESS. (AS APPLICABLE). DELEGATE CONTACT NO.: DELEGAT

Entry form for website.pdf
... 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.

APPLICATION FORM FOR OBC PREMATRIC SCHOLARSHIP 2014 ...
APPLICATION FORM FOR OBC PREMATRIC SCHOLARSHIP 2014-15.pdf. APPLICATION FORM FOR OBC PREMATRIC SCHOLARSHIP 2014-15.pdf. Open.

Medication Verification Form for Physicians.pdf
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 ...

Application form for the MDH scholarship
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- ...

APPLICATION FORM FOR COPYING AGENCY.pdf
Page 3 of 15. Page 3 of 15. APPLICATION FORM FOR COPYING AGENCY.pdf. APPLICATION FORM FOR COPYING AGENCY.pdf. Open. Extract. Open with.

CRCW HOA Form for Complaints.pdf
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.

SPANISH - Website - REQUEST FORM FOR NEXT YEAR ...
SPANISH - Website - REQUEST FORM FOR NEXT YEAR TRANSPORTATION.pdf. SPANISH - Website - REQUEST FORM FOR NEXT YEAR ...

DREAM PROPOSAL FORM for OCTOBER 2015 INTAKE
2. - “Tools for developing, managing and analysing 'Big Data', to understand risk better, ... www.bafg.de/GRDC/EN/Home/homepage_node.html), International ...

PreRegistration Form for New Students.pdf
Lunenburg Public Schools. www.lunenburgonline.com. Page 1 of 1. PreRegistration Form for New Students.pdf. PreRegistration Form for New Students.pdf.