PART I: HISTORY OF PHYSICAL ACTIVITY: (This record is a critical Have you had any other chronic medical problems (diabetes, anemia, mononucleosis, asthma) …
PHYSICAL EXAM AND ACTIVITY RELEASE
Full Name of Student: ______________________________________ Date of
Birth: ________________
Last First Middle
Home Address: ________________________________City/State:
_________________ Zip: ____________
Age: ________ Gender: ________ Race: ________Grade: ________Home Phone:
__________________
Previous school attended:
____________________________________________________________________
Personal Physician: ___________________________________ Phone:
_______ ____________________
PART I: HISTORY OF PHYSICAL ACTIVITY: This record is a critical element
in the determination of a students risk of injury while participating in
athletics/physical activity Please read each item carefully and note
responses before seeing a physician for the students physical
examination
Explain YES answers below: NO YES
EXPLAIN
1 Have you ever been hospitalized?
________________________________
Have you ever had surgery?
_________________________________
Are you presently under a doctors care?
_________________________________
2 Are you presently taking any medication, either prescription or over-
the-counter? _________________________________
3 Do you wear dental appliances or hearing aids?
_________________________________
4 Do you have any allergies medicine, bees or other stinging insects,
foods? _________________________________
Do you have any skin problems rashes, acne, psoriasis?
_________________________________
5 Have you ever passed out during or after exercise?
_________________________________
Have you ever been dizzy during or after exercise?
_________________________________
Have you ever had chest pain during or after exercise?
_________________________________
Do you have trouble breathing or do you cough during or after
exercise?
_________________________________
6 Have you ever had high blood pressure?
_________________________________
Have you ever been told that you have a heart murmur?
_________________________________
Have you ever had racing of your heart or skipped heartbeats?
_________________________________
Has anyone in your family died of heart problems or sudden death
before age 50? _________________________________
Has anyone in your family had Marfans Syndrome?
_________________________________
7 Have you ever had a head or neck injury?
_________________________________
Have you ever been knocked out or unconscious?
_________________________________
Have you ever had a concussion?
_________________________________
8 Have you ever had a back or spinal injury?
_________________________________
9 Have you
ever had a seizure or epilepsy?
_________________________________
10 Have you ever had heat exhaustion or heatstroke?
_________________________________
Have you ever had heat cramps or muscle cramps?
_________________________________
11 Have you had any other chronic medical problems diabetes, anemia,
mononucleosis, asthma?
_________________________________
12 Do you have any problems with your eyes or vision?
_________________________________
Do you wear glasses, contact lenses, or protective eyewear?
_________________________________
13 Has any physician limited your athletic participation for any reason?
_________________________________
Do you use any special equipment during athletic participation
braces, etc? _________________________________
14 Have you ever sprained, dislocated, broken or had repeated swelling or
other injury of:
Hand
Wrist Elbow Arm Shoulder
Foot Ankle
Knee Leg Hip Back Neck
Other: ________________
15 Do you have only one of any paired organ eyes, kidneys, testicles,
ovaries? _________________________________
16 Have you had a medical problem or injury since your last physical
exam? _________________________________
17 When was your last tetanus shot?
_________________________________________________________________
PART II: MEDICAL HISTORY
Student Full Name: ________________________________________________________
Date of birth: _____________
LAST FIRST MIDDLE
Race ________________ Gender ____________________ Grade
___________________
Parents/Legal Guardians: _____________________________________________
Phone: _______________________
Address: ______________________________________ City:
_____________________ State: _________ Zip: __________
PERSONAL HISTORY check where applicable
_____ Abnormal Bleeding _____ Ear, Nose, Throat
Problems _____
Mononucleosis
_____ ADHD/Learning Disability _____ Eating Disorder
_____ Mumps
_____ Alcohol Use _____ Epilepsy/Seizures
_____ Pneumonia
_____ Anemia/Blood Disorder _____ Eye Problems _____
Rheumatic Fever
_____ Anxiety _____ Food Allergies _____
Seasonal allergies
_____ Arthritis _____ Fractures/Sprains
_____ Sexually transmitted disease
_____ Asthma/Wheezing _____ Frequent Indigestion/GERD
_____ Sinusitis
_____ Back Problems _____ Headaches _____
Skin problems
_____ Cancer/Tumor _____ Head injury/concussion
_____ Special Diet
_____ Chest Pain _____ Heart Disease _____
Stomach Ulcer
_____ Chicken Pox _____ Hepatitis/Jaundice
_____ Tuberculosis
_____ Counseling/Psychotherapy _____ Hernia
_____ Thyroid/Hormone Problem
_____ Chronic Cough _____ High Blood Pressure _____
Tobacco Use
_____ Congenital Heart Problems _____ HIV/AIDS
_____ Typhoid Fever
_____ Dental Problems _____ Insomnia
_____
Unusual Childhood Disease
_____ Depression _____ Intestinal/Digestive Problem
_____ Urinary Tract Infection
_____ Diabetes _____ Kidney Disease FEMALES
ONLY:
_____ Diminishing Hearing _____ Malaria
_____ Irregular periods
_____ Dizziness/Fainting Spells _____ Measles
_____ Severe cramps
_____ Drug Use _____ Migraines _____
Excessive flow
FAMILY HISTORY Parents, Siblings, Grandparents Check where applicable
_____ Anemia _____ Diabetes _____
Migraines
_____ Arthritis _____ Epilepsy/Seizures _____
Stroke
_____ Asthma _____ Heart Disease _____ Sudden
Death
_____ Blood Disorder _____ High Blood Pressure ______
Thyroid Disease
_____ Cancer _____ Intestinal Disease ______
Other: specify
Are you under treatment for any medical/emotional condition?
describe
________________________________
____________________________________________________________________________
______________________________
____________________________________________________________________________
______________________________
____________________________________________________________________________
______________________________
ALLERGIES check where applicable
No know allergies Sulfa
Food: ____________________
Aspirin Other medications:
Insect: ___________________
Penicillin _______________________ Animal:
__________________
Codeine _______________________
Other: ___________________
MEDICATIONS currently being used: check where applicable
None
Vitamins:
____________________________________________________________________________
_______________
Herbal supplements:
____________________________________________________________________________
___
Oral Contraceptives:
____________________________________________________________________________
___
Prescription
Medications:
___________________________________________________________________________
Over the counter:
____________________________________________________________________________
______
The pre-participation questionnaire and examination is limited and designed
to identify common conditions or infirmities that would limit or prevent a
student from participating in athletics or typical physical activities
associated with our residential programming The examination is NOT meant
to be comprehensive and may not detect some types of latent or hidden
medical conditions All students should receive a periodic comprehensive
medical examination and prompt treatment of illnesses and/or injuries
I hereby state that, to the best of my knowledge, my answers to the above
questions are correct Furthermore, I give permission for this pre-
participation physical examination of my child or ward
Signature of student: _______________________________________________
Date: ___________________________
Signature of parent/guardian: _______________________________________
Date: ___________________________
PART III: PHYSICAL EXAM - TO BE COMPLETED BY PHYSICIAN:
PART III: PHYSICAL
EXAM MUST BE FILLED OUT IN ITS ENTIRETY Please review
the students history as provided on earlier pages of this document
Please attach a separate letter detailing the medical history and
management plan for any serious or chronic illness not addressed on this
form
Height: ______ ft ______ in Weight: ________ lbs BP:
_________/__________ Pulse: _____________
Skeletal Size: Small ______ Medium ______ Large ______ ExLarge ______
BMI ___________________
Laboratory: Hemoglobin or Hematocrit: _____________________ Urine:
__________ __________ _______
Circle One Value SpGr
Protein Sugar
ATTACH A COPY OF RESULTS FOR ONE OF THE FOLLOWING:
Acid Fast Smear _________________ First Morning Sputum _______________
Tuberculin Skin Test _____________
IMMUNIZATION HISTORY:
| |DPT |MMR |Polio |HepB |Meningiti|Varicella |HPV |
| | | | | |s | | |
|Current | | | | | | | |
|Not Current| | | | |
| | |
|Not | | | | | | | |
|applicable | | | | | | | |
EYES: Are glasses worn? YES NO Is color vision
defective? YES NO
Pupils: Equal Unequal If unequal, RL
LR
Right: __________/__________ uncorrected Left:
__________/__________ uncorrected
__________/__________ corrected
__________/__________ corrected
EARS: Is hearing normal? YES NO Are drums intact? YES
NO
| |Normal |Abnormal Findings |
|Skin | | |
|Head, Face, Neck | | |
|Nose Sinuses | | |
|Mouth Throat | | |
|Teeth | | |
|Lungs Chest | |
|
|Heart | | |
|Vascular System | | |
|Abdomen | | |
|Endocrine | | |
|Spine | | |
|Neurologic | | |
|Musculoskeletal | | |
|ROM, Strength, | | |
|etc | | |
|Neck | | |
|Spine scoliosis | | |
|Shoulders | | |
|Elbows | | |
|Wrists
| | |
|Arms/hands | | |
|Hips | | |
|Thighs | | |
|Knees | | |
|Ankles | | |
|Feet | | |
|Other | | |
Male students: Female Students:
Hernia Normal Abnormal Breasts
Normal Abnormal
Genitalia Normal Abnormal Pelvic Normal
Abnormal
Is there or has there been any physical or emotional problem that is likely
to interfere with this students adjustment to residential life or
participation in physical activity? NO YES
If YES, please
explain:
____________________________________________________________________________
________
____________________________________________________________________________
______________
____________________________________________________________________________
____________________________________________________________________________
____________________________
Please itemize any regular prescription medications or reoccurring
treatment needs of this student allergy shots, counseling, etc which
must be continued while enrolled at the Mississippi School for Mathematics
and Science:
____________________________________________________________________________
______________
____________________________________________________________________________
____________________________________________________________________________
____________________________
____________________________________________________________________________
______________
Please Print/Stamp
|Physicians Name | |
|Street Address | |
|City, State, Zip Code|
|
|Telephone | |
PHYSICIANS STATEMENT:
I certify that I am a licensed physician or family nurse practitioner and
that I have examined this student At the time of examination, no physical
condition was detected which would reasonably be anticipated to render this
student unfit to engage in intramurals, MHSAA athletics, or moderately
strenuous exercise, except as noted below
RESTRICTIONS:
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
____________________________________________________________________________
_______________________________
Additional recommendations regarding
health/wellness:
____________________________________________________________________________
_______________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________
Signature of Physician: ___________________________________________
Date: ____________________________
———————–
Source:msms.k12.ms.us
