Physical Evaluation Form printable pdf download

Kennewick School District 17

PHYSICAL EVALUATION

Section A: To Be Completed By Parent

 Male

 Female

Student Legal Name ________________________________________________________________

Address____________________________________________________City________________________Zip ___________

Phone __________________________

Grade in the Fall _________________________ School in the Fall _______________________________________________

Activity: Fall ___________________________ Winter ________________________ Spring _________________________

Explain all “Yes” answers with dates and details in the area following the question.

Yes

Have you had any illness/injury recently, or do you have an illness/injury now? Explain

Have you had a medical problem, illness or injury since your last exam?

Do you have any chronic or recurrent illness? List

Have you ever hand any illness lasting more than a week? List

Have you ever been hospitalized overnight?

Have you ever had surgery other than a tonsillectomy? List

Have you ever had any injuries requiring treatment by a physician? List

Do you have any organ missing other than tonsils (appendix, eye, kidney, testicle, etc)? List

Are you presently taking ANY medications (including birth control pill, vitamin, aspirin, etc)? List

Do you have ANY allergies (medicine, bees, foods, etc)? List

Have you ever had chest pain, dizziness, fainting, passing out during or after exercise?

Do you tire more easily or quickly than your friends during exercise?

Have you ever had any problem with your blood pressure or your heart?

Have any of your close relatives had heart problems, heart attack or sudden death before they were age 50?

Do you have any skin problems (acne, itching, rashes, etc)? List

Have you ever had fainting, convulsions, seizures or severe dizziness?

Do you have frequent severe headaches?

Have you ever had a “stinger” or “burner” or pinched nerve?

Have you ever been “knocked out” or “passed out”? Date & details

Have you ever had a neck or head injury? Date and severity

Have you ever had heat exhaustion, heat stroke, heat cramps or similar heat-related problems?

Have you had asthma, trouble breathing, or cough during or after exercise?

Do you wear glasses or contacts or protective eye wear?

Have you had any problems with your eyes or vision?

Do you wear any dental appliance such as braces, bridge, plate, retainer?

Have you ever had a knee injury?

Have you ever had an ankle injury?

August 2009

Physical Evaluation Form