STUDENT SPORTS PHYSICAL HISTORY FORM
Students Name DOB
Address Grade
Physician
Sports
FILL IN DETAILS OF YES ANSWERS IN SPACE BELOW
YES NO
1. Has the above student ever been hospitalized? __________
Has the above student ever had surgery? __________
2. Is the above student presently taking medication? __________
3. Does the above student have any allergies (meds., bees)? __________
4. Has the above student ever passed out during exercise? __________
5. Has the above student ever been dizzy during exercise? __________
6. Has the above student ever had chest pain? __________
7. Does he/she tire quicker than his/her friends during exercise? __________
8. Has the above student ever had high blood pressure? __________
9. Has the above student ever been told he/she has a heart murmur? __________
10.Has the above student ever had a racing heart or skipped beat? __________
11.Has anyone in your family died of heart problems or sudden
death before age 40? __________
12.Does the above student have any skin problems? __________
(Itching, Moles, Breaking Out) __________
13.Has the above student ever had a head injury?
14.Has the above student ever been knocked out?
15.Has the above student ever had a seizure?
16.Has the above student ever had a stinger or burner?
17.Has the above student ever injured (sprained, dislocated, fractured, etc.)
_______Hand _______Shoulder _______Thigh _______Wrist
_______Neck _______Knee _______Forearm _______Chest
_______Shin/Calf _______Elbow _______Back _______Ankle
_______Arm _______Hip _______Foot
18.Has the above student ever had heat cramps?
19.Has the above student ever had:
Mononucleosis Diabetes
Hepatitis Headaches
Asthma Eye Injuries
Tuberculosis Stomach Ulcer
20. Does the above student use special pads or braces?
21. When was the above student's last tetanus shot?
Explain “YES” answers here:
School Year