|
|
Medical Questions for Parents |
YES | NO |
| 1. Family history of sudden death before age 50? | ||
| 2. Dizziness/fainting/chest pain with exercise? | ||
| 3. Heart murmur/heart condition? | ||
| 4. High Blood Pressure? | ||
| 5. Bone or joint injury (especially back or hips)? | ||
| 6. Sprain/dislocation? | ||
| 7. Serious head or spine trauma/repeated concussions/surgery on head or back? | ||
| 8. Detached retina? | ||
| 9. Known current illness/infection? | ||
| 10. Uncontrolled asthma? | ||
| 11. Uncontrolled seizures? | ||
| 12. Recurrent skin disorders (boils, impetigo)? | ||
| 13. Loss or serious impairment of a paired organ (kidney, eye, lung, testes)? | ||
| 14. Known liver/spleen/kidney enlargement/mononucleosis/hepatitis? |
____________________________
___________
Signature of
Parent
Date
Physical Exam (To be completed by physician)
| Blood Pressure | Dentition | ||
| Lungs | Heart | ||
| Murmur? | Change with Valsalva? | ||
| Abdomen - Organ Enlargement? | Testes | ||
| Musculoskeletal | Skin |
Sports Participation
Approved
YES
NO
Return to Forms
____________________________
___________
Signature of
Physician
Date