Blue Medical Form (Page 2 of 2) in pdf

** ATHLETIC MEDICAL HISTORY: To be completed by PARENT/GUARDIAN **

Name of Student Athlete: _____________________________

Date of Birth: __________________________________

Date of Physical Exam/Sport exam: _____________________

Name of Child’s Doctor: ______________________________

Phone: _________________________________

In order for your child to participate in the above named athletic/sport program, a physical examination MUST have been

completed within thirty six (36) months prior to the start of the sport. Her/his health condition at the time must have

been found acceptable for participating in this sport.

Does your child have any allergies? No___ Yes___ if Yes, list allergy ______________________________________

Has you child ever had to carry a bee sting kit, an EPIPEN, or other allergy medication?

No___ Yes___ if yes, name of medication: __________________________________________________________

** if yes, medication and doctor’s authorization must be given to the coach before participation.

Does your child have Asthma/wheezing? Yes___ No___ Does your child currently, or in the past year, or for sports use an inhaler or other

Medication for Asthma? Yes___ No___ If Yes, name of Medication: ______________________________________________________________

** if yes, medication and doctor’s authorization must be given to the coach before participation**

Does your child wear contacts: __ Braces __ Loose Tooth __ False Teeth __ Hearing Aid __

Does your child take medication every day? No___ Yes___ If yes, names of medication: _______________________________________________

For female students: are you pregnant? Yes__ No__ If yes, doctor’s note needed to participate

HAS YOUR CHILD HAD ANY OF THE FOLLOWING

Kidney problems, only one kidney or kidney disease? Yes__ No__ if yes, Explain: ___________________________________________________________

Problems with bruising or bleeding easily or trouble stopping bleeding? Yes__ No__ if yes, explain: _____________________________________________

Seizures, Epilepsy or Convulsion? No__ Yes__ if yes, explain:____________________________________________________________________________

Diabetes, low blood sugar or high blood sugar? No__ Yes__ if yes, explain: ________________________________________________________________

Fainting Spells? No__ Yes__ if yes, explain: __________________________________________________________________________________________

Mononucleosis? No__ Yes__ if yes, explain: _________________________________________________________________________________________

Have a concussion, head injury, been knocked out or unconscious? No__ Yes__ if yes, explain:_________________________________________________

High blood pressure, heart problems, chest pain, or shortness of breath? No__ Yes__ if yes, explain: ____________________________________________

A serious eye injury? No__ Yes__ if yes, explain: ______________________________________________________________________________________

A spine, neck, back injury, or any other injury? No__ Yes__ if yes, explain _________________________________________________________________

Bone, joint, neck or back pain? No__ Yes__ if yes, explain: ______________________________________________________________________________

A broken bone, fracture, sprain or strain ankle, foot or knee problems? No__ Yes__ if yes, explain: _____________________________________________

Any hospital admissions or surgery? No__ Yes__ if yes, explain; _________________________________________________________________________

Any other health problems? No__ Yes__ if yes, explain: ________________________________________________________________________________

To the bes of my knowledge, the medical history that I supplied above is correct and accurate. I understand that if any change in my child’s health status occurs since

completing this form or during his/her participation in this sport, I will notify my child’s physician, the sport coach and the school nurse of any health status change.

Signature of Parent/Legal Guardian: ___________________________________ Date: ____________________________

Phone Numbers where parent can be reached during sports: (H)________________________ (W)________________________(C)___________________