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ANNUAL PHYSICAL EXAMINATION
NAME (LAST, FIRST, MIDDLE)
MUST BE COMPLETED AND SIGNED BY M.D. OR D.O.
DATE OF EXAM
OFFICE OF ATHLETICS PO BOX 1335 JEFFERSON CITY, MO 65102 (573) 751-0243 FAX (573) 751-5649
SOCIAL SECURITY NO.
DATE OF BIRTH
MEDICAL HISTORY (PLEASE COMPLETE AS THOROUGHLY AS POSSIBLE)
A. HAS APPLICANT EVER HAD ANY OF THE FOLLOWING CONDITIONS, PLACE AN “X” IF IT APPLIES TO YOU
Fainting Spells Shortness of Breath Frequent Headaches Spitting of Blood
1. HAVE YOU EVER BEEN HOSPITALIZED?
Rupture (hernia) Chest Pain Swollen Joints Rheumatism Convulsions (fits) Chronic Cough Cerebral Hemorrhage or any other serious head injury
Operations Diabetes Bleeding Disorder
If “yes”, give nature of problem(s), date(s), location(s) and attending physicians:
2. HAVE YOU EVER HAD EYE SURGERY?
If “yes”, explain:
3. HAVE YOU EVER HAD A RETINAL DETACHMENT?
If “yes”, explain:
4. DO YOU REGULARLY OR OCCASIONALLY TAKE ANY MEDICATIONS?
If “yes”, give name(s), frequency and dose:
5. HAVE YOU PREVIOUSLY BEEN INJURED IN A BOXING/KICKBOXING/MARTIAL, WRESTLING ARTS EVENT?
If “yes”, describe injuries:
6. LONGEST DURATION OF UNCONSCIOUSNESS
7. WHAT IS YOUR RECORD?
Wins __________ Wins __________
Losses __________ Losses __________
Draws __________ Draws __________ Number of times lost by TKO or KO __________
8. WHAT IS YOUR RECORD FOR THE LAST YEAR?
9. WHEN WERE YOU LAST GIVEN A MEDICAL SUSPENSION FROM A COMMISSION? (DATE)
10. WHY WERE YOU SUSPENDED?
11. (WOMEN CONTESTANTS ONLY) DATE OF LAST MENSTRUAL PERIOD
HEIGHT WEIGHT TEMPERATURE
External Trauma Perforated Drum
Yes Yes Yes Yes Normal
No No No No Abnormal
Instability Recent Trauma Obstruction
Yes Yes Yes
No No No
Recent Trauma Jaw and Temporomandibular Joints
MO 375-0299 (9-08)
the date the authorization is signed. kick boxing. of each even numbered year and is relevant to all medical records described herein. any and all of my medical records concerning my licensure as a participant including. or subsequent to. (ABC). that the signing of this Medical Information Release is optional. By signing below. martial arts or wrestling match. and any other information regarding conditions related to the propriety of my licensure as a participant (including history. I understand. kick boxing. that the medical records described herein will not be released for any purpose other than for a member commission affiliated with the ABC to determine my eligibility to participate in a professional boxing. findings. and that my declining to sign this document will not result in any adverse action being taken against me by the Office of Athletics based on my decision. I also attest that I do not have a professional relationship with. hepatitis virus and drug screening. PRINT NAME OF EXAMINING PHYSICIAN PHYSICIAN’S LICENSE NUMBER SIGNATURE OF EXAMINING PHYSICIAN ADDRESS OF PHYSICIAN TELEPHONE NUMBER OF PHYSICIAN MEDICAL RELEASE OF INFORMATION I hereby authorize the Office of Athletics to release. and it is agreed. diagnosis. or prognosis).D. disclose. that this authorization shall remain in effect until June 30. hospital records. this individual is or is not medically fit to participate as a contestant in a professional boxing. and it is agreed.O. I hereby authorize the release of my medical information.PHYSICAL EXAM (CONTINUED) ABDOMEN ENLARGED GLANDS GOITER Enlargement of Liver Hernia Enlargement of Spleen CARDIOVASCULAR Yes Yes Yes No No No Yes Femoral No Inguinal Yes Ventral No Blood Pressure (supine) ___________________________ (upright) ___________________________ Blood Pressure after 100 hops ___________________________ Blood Pressure 2 minutes later ___________________________ Heart Rate (supine) ___________________________ (after 2 minutes of exercise) ___________________________ HEART Pulse Rhythm Enlargement BREAST (WOMEN CONTESTANTS) Normal Yes Yes Abormal Normal Normal Normal Normal Normal Abnormal No No Apical Impulse Murmurs Tenderness Heavy Yes Yes Normal No No Mass Normal MUSCULOSKELETAL GYNECOLOGICAL EXAMINATION (WOMEN CONTESTANTS) Hands Wrists Elbows Shoulder Girdle Lower Extremities NEUROLOGIC Abnormal Abnormal Abnormal Abnormal Abnormal Comments: Comments: Comments: Comments: Comments: ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Mental Status Cranial Nerves Tone Coordination: Finger to Nose COMMENTS OF EXAMINING PHYSICIAN Orientation __________________/3 5-minute recall __________________/3 Normal Abnormal Strength Normal Abnormal Gait Normal Abnormal Tandem Gait Normal Normal Normal Abnormal Abnormal Abnormal I hereby certify that I have examined the named individual and in my opinion. OR D. I understand. nor financial interest in the earnings of this individual. MUST BE COMPLETED AND SIGNED BY M. and furnish to any other boxing or athletic commission affiliated with the Association of Boxing Commissions. whether such record were created prior to. and it is agreed. martial arts contest or wrestling. all required medical examinations. but not limited to. I understand. laboratory test results for the HIV. PRINT NAME SIGNATURE OF BOXER DATE MO 375-0299 (9-08) .