2010 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.

Yes No Yes No
1 Have you had a medical illness or injury since your last ____ ____ 26 Have you ever become ill from exercising in the heat? ____ ____
physical?
2 Do you have on going chronic illness? ____ ____ 27 Do you cough, wheeze, or have trouble breathing during ____ ____
activity?
3 Have you ever been hospitalized overnight? ____ ____ 28 Do you have asthma? ____ ____
4 Have you ever had a surgery? ____ ____ 29 Do you have seasonal allergies? ____ ____
5 Are you currently taking medication? ____ ____ 30 Do you “need” to use any special protective or corrective ____ ____
equipment that are not a part of the issued uniform?
6 Are you taking any supplements? ____ ____ 31 Have you ever had problems with your eyes or vision? ____ ____
7 Do you have allergies? ____ ____ 32 Do you wear glasses, contacts, or protective eye wear? ____ ____
8 Have you ever had a rash develop after exercise? ____ ____ 33 Have you ever had swelling after a sprain, strain, or injury? ____ ____
9 Have you ever passed out during or after exercise? ____ ____ 34 Have you ever broken or fractured a bone? ____ ____
10 Have you ever been dizzy during exercise? ____ ____ 35 Have you ever had any problems with pain or swelling in ____ ____
muscles, tendons, bones, or joints?
11 Have you ever had chest pain during exercise? ____ ____ 36 Record the dates of your most recent immunizations (shots): ____ ____
12 Do you get tired more quickly than your friends? ____ ____ ____ ____
13 Do you have (or ever had) an irregular heartbeat? ____ ____ Tetanus: _______________ Measles: _________________ ____ ____
14 Do you have high blood pressure? ____ ____ ____ ____
15 Have you ever been told you have a heart murmur? ____ ____ Hepatitis B: _____________ Chickenpox: ______________ ____ ____
16 Has any relative died of heart failure prior to age 50? ____ ____ ____ ____
17 Have you had a severe viral infection within the last month? ____ ____ ____ ____
18 Has a physician ever restricted you from activity? ____ ____ ____ ____
19 Do you have any current skin problem? ____ ____ ____ ____
20 Have you ever had a head injury or concussion? ____ ____ ____ ____
21 Have you ever been knocked out or become unconscious? ____ ____ ____ ____
22 Have you ever had a seizure? ____ ____ ____ ____
23 Do you have frequent headaches? ____ ____ ____ ____
24 Have you ever had numbness or tingling limbs? ____ ____ ____ ____
25 Have 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: _______
Physical Examination (to be completed by physician).

Participant’s Name: _________________________________________________ Date of Birth: __________________________

Height: ___________________ Weight: __________________ Pulse: _____________ Blood Pressure: _________ / __________

Visual Acuity: Right 20/_______ Left 20/________ Corrected: Yes No Pupils: Equal _________ Unequal____________

Findings Normal Abnormal Findings Initials

Medical
1. Appearance ______ _______________________________________________________ _______
2. Eyes/Ears/Nose/Throat ______ _______________________________________________________ _______
3. Lymph Nodes ______ _______________________________________________________ _______
4. Hear ______ _______________________________________________________ _______
5. Pulses ______ _______________________________________________________ _______
6. Lungs ______ _______________________________________________________ _______
7. Abdomen ______ _______________________________________________________ _______
8. Genitalia (males) ______ _______________________________________________________ _______
9. Skin ______ _______________________________________________________ _______

Musculoskeletal

10. Neck ______ ________________________________________________________ _______

11. Back ______ ________________________________________________________ _______
12. Shoulder/Arm ______ ________________________________________________________ _______
13. Elbow/Forearm ______ ________________________________________________________ _______
14. Wrist/Hand ______ ________________________________________________________ _______
15. Hip/Thigh ______ ________________________________________________________ _______
16. Knee ______ ________________________________________________________ _______
17. Leg/Ankle ______ ________________________________________________________ _______
18. Foot ______ ________________________________________________________ _______

Assessment

______ Cleared without limitation

______ Cleared after completing evaluation/rehabilitation for: _____________________________________________________

______ NOT Cleared Reason: ___________________________________________________________________________

Name of physician (print): ____________________________________________________________ Date: _________________

Address: ________________________________________________________________________________________________

Signature of physician: ___________________________________________________________________________, MD or DO