2009 Participation Physical Evaluation
This completed form must be submitted to FBCN SportsOutreach and kept on file.
Participant Information (to be completed by participant or parent).
Name: ____________________________________________ Sex: ________ Age: ______ Date of Birth: ___________________ Grade in School: ____________ Sport(s): ______________________________________________________________________ Home Address: ___________________________________________________________________________________________ Name of Parent / Guardian: __________________________________________ Relationship to Participant: ________________ Home Phone: _________________________________________ Cell Phone: _________________________________________ Work Phone: __________________________________________Email: _____________________________________________ Emergency Contact: _____________________________________________ Phone Number: ____________________________ Personal Physician: ________________________________ City / State: ____________________ Phone: __________________
Medical History (to be completed by student or parent). Explain “yes” answers below. Circle Questions you don’t understand.
YesNoYesNo1Have you had a medical illness or injury since your last physical? ________26Have you ever become ill from exercising in the heat?________ 2Do you have on going chronic illness?________27Do you cough, wheeze, or have trouble breathing duringactivity? ________ 3Have you ever been hospitalized overnight?________28Do you have asthma?________ 4Have you ever had a surgery?________29Do you have seasonal allergies?________ 5Are you currently taking medication?________30Do you “need” to use any special protective or correctiveequipment that are not a part of the issued uniform? ________ 6Are you taking any supplements?________31Have you ever had problems with your eyes or vision?________ 7Do you have allergies?________32Do you wear glasses, contacts, or protective eye wear?________ 8Have you ever had a rash develop after exercise?________33Have you ever had swelling after a sprain, strain, or injury?________ 9Have you ever passed out during or after exercise?________34Have you ever broken or fractured a bone?________ 10Have you ever been dizzy during exercise?________35Have you ever had any problems with pain or swelling inmuscles, tendons, bones, or joints? ________ 11Have you ever had chest pain during exercise?________36Record the dates of your most recent immunizations (shots):________ 12Do you get tired more quickly than your friends?________________ 13Do you have (or ever had) an irregular heartbeat?________Tetanus: _______________ Measles: _________________________ 14Do you have high blood pressure?________________ 15Have you ever been told you have a heart murmur?________Hepatitis B: _____________ Chickenpox: ______________________ 16Has any relative died of heart failure prior to age 50?________________ 17Have you had a severe viral infection within the last month?________________ 18Has a physician ever restricted you from activity?________________ 19Do you have any current skin problem?________________ 20Have you ever had a head injury or concussion?________________ 21Have you ever been knocked out or become unconscious?________________ 22Have you ever had a seizure?________________ 23Do you have frequent headaches?________________ 24Have you ever had numbness or tingling limbs?________________ 25Have you ever had a stinger or burner, or pinched nerve?________________
Explain “Yes” answers here: ________________________________________________________________________________ ________________________________________________________________________________________________________
I hereby state, to the best of my knowledge, that my answers to the above questions are complete and correct.Signature of Participant: _______________________ Date: ___________ Signature of Parent / Guardian: _______________________________ Date: _______