Fulton County Student Preparticipation Medical History / Physical Examination Form
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2FULTON COUNTY STUDENT PREPARTICIPATION MEDICAL HISTORY / PHYSICAL EXAMINATION FORM
This form is to be completed by the Parent/Guardian/Student and returned to the coach prior to the first practice session.
Student Name: _________________________________________________ Male __ / Female __ DOB: _____________________
(Last Name)
(First Name)
(MI)
(Month)
(Day)
(Year)
Address:________________________________________________________________
Home Tel, #: __________________
(# and Street Name)
(City)
(State)
(Zip Code)
6
7
8
Emergency Tel. # ________________Cellular Tel. #:________________ Grade this school year:
Name(s) of parent(s) /guardian(s) you live with: _________________________________________________________.
In Case of Emergency Contact: _____________________Relationship: _______________ Tel. #: ________________________
Personal Physician’s Name: ______________________________________________ Tel. #: ____________________________
Explain “YES” answers in the item spaces provided on next page. Circle #s to questions that you do not know the answers.
#
MEDICAL QUESTION
YES
NO
#
MEDICAL QUESTION
YES
NO
1
Have you had a medical illness or injury since your
24
Do you have frequent or severe headaches?
last check up or sports physical?
2
25
Have you ever been hospitalized overnight?
Have you ever had numbness or tingling in your
arms, hands, legs, or feet?
3
Have you ever had surgery?
26
Have you ever had a stinger, burner, or pinched
nerve?
4
Are you currently taking any prescription or non
27
Have you ever become ill from exercising in the
prescription (over- the-counter) medications or pills
heat?
or using an inhaler?
5
Have you ever taken any supplements or vitamins
28
Do you cough, wheeze, or have trouble breathing
to help you gain or lose weight or improve your
during or after activity?
performance?
6
Do you have any allergies (for example, to pollen,
29
Do you have asthma?
medicine, food, or stinging insects)?
7
30
Have you ever had a rash or hives develop during
Do you have seasonal allergies that require medical
or after exercise?
treatment?
8
Have you ever passed out during or after exercise?
31
Do you use any special protective or corrective
equipment or devices that aren't usually used for
your sport or position (for example, knee brace,
special neck roll, foot orthotics, retainer on your
teeth, hearing aid)?
9
Have you ever been dizzy during or after exercise?
32
Have you had any problems with your eyes or
vision?
10
33
Have you ever had chest pain during or after
Do you wear glasses, contact lenses, or protective
exercise?
eyewear?
11
Do you get tired more quickly than your friends do
34
Have you ever had a sprain, strain, or swelling after
during exercise?
injury?
12
Have you ever had racing of your heart or skipped
35
Have you broken or fractured any bones or
heartbeats?
dislocated any joints?
13
Have you had high blood pressure or high
36
Have you had any other problems with pain or
cholesterol?
swelling in muscles, tendons, bones, or joints?
If yes to Question # 36 then circle the part of the body below:
14
Have you ever been told you have a heart murmur?
37
15
Has your family member or relative died of heart
Head
Elbow
Hip
Neck
Forearm
Thigh
problems or of sudden death before age 50?
16
Have you or any family member or relative been
Back
Wrist
Knee
Chest
Hand
Finger
diagnosed with diabetes before age 50?
17
Have you had a severe viral infection (for example,
Shin/calf
Foot
Ankle
Shoulder
Upper arm
myocarditis or mononucleosis) within the last
month?
18
Has a physician ever denied or restricted your
participation in sports for any heart problem?
19
Do you have any current skin problems (for
example, itching, rashes, acne, warts, fungus, or
blisters)?
20
Have you ever had a head injury or concussion?
21
Have you ever been knocked out, become
38
Do you want to weigh more or less than you do
unconscious, or lost your memory?
now?
22
Have you ever had a seizure?
39
Do you lose weight regularly to meet weight
requirements for your sport?
23
Is there a history of Marfan’s Syndrome in your
40
Do you feel stressed out?
family?
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