MIDDLE SCHOOL ATHLETIC HEALTH EXAMINATION FORM

Part I: To be completed by parent or guardian.

Name:___________________________ Grade:_________

Address:_________________________________________

Phone Number:________________

Date of Birth:_________________Age:_______Race:_________Sex:_________

Incase of emergency, please notify:

Name:_______________________Relationship:_______________

Phone number:________________Work Phone:_______________

Medical History

List any history of medical problems with: bleeding tendencies, anemia (low blood), chronic disease, scarlet fever, rheumatic fever, joint injuries, seizures, concussions, diabetes, or operation.

None/List:______________________________________Dates:____________________

Other medical problems:____________________________________________________

Medications now taking:____________________________________________________

Part II: To be completed by a physician

Height_______(inches) Weight_________(lbs)

Blood pressure_______/________

Vision Right eye_______ With lenses_________

Left eye________ With lenses_________

Functional orthopedic

Upper extremity__________________________________________________________

Lower extremity__________________________________________________________

Spinal evaluation__________________________________________________________

Upper body (heart, lungs, ribcage)____________________________________________

Lower body (Hernia, organomegaly, Absence of paired organ)_____________________

I certify that I have on this date examined this pupil and find him/her physically able to compete in the middle school athletic program.

______Full participation

______Needs further evaluation for the following disqualifying reasons: ________________________________________________________________________________________________________________________________________________

Physician:___________________________________Date:________________________

Address:____________________________________Phone:_______________________