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Tackle Football Participation Physical Evaluation

Tackle Football Participation Physical Evaluation

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Published by fbcnsportsoutreach

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Published by: fbcnsportsoutreach on Jun 07, 2009
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01/17/2015

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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 needto 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: _______ 

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