Have you ever injured any other joint (shoulder, wrist, fingers, etc)?
Have you ever had a broken bone (fracture)?
Have you ever had a cast, splint, or had to use crutches?
Must you use special equipment for competition (pads, braces, neck roll, etc)?
Has it been more than five (5) years since your last tetanus booster shot?
Are you worried about your weight?
Females: Have you any menstrual problems?
Have you any medical concerns about participating in your activity?
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Student Signature _____________________________________________ Date _________________________
Parent/Guardian Signature______________________________________ Date _________________________
Section B: To Be Completed By Physician
Age ______ Height _________
Weight ________
BP ___________
Pulse ________ Visual Acuity L 20/__ R 20/__
Normal
Abnormal Findings
Initials
Head
Eyes, ENT
Teeth
Chest
Lungs
Heart
Abdomen
Genitalia
Neurologic
Skin
Physical Maturity
Spine, Back
Shoulders, Upper Extremities
Lower Extremities
Assessment: Full Participation
Limited Participation (describe limitations, restrictions in box below)
Participation contraindicated (list reasons in box below)
Recommendation (equipment, taping, rehab, etc):
Date ___________________ Physician’s Signature_____________________________ Print Physician Name ______________________________
August 2009