REGION 15 SPORTS PHYSICAL EXAMINATION
"Serving the Educational Needs of Middlebury and Southbury"
                                                                                                                            Grade________________________
Name_______________________________________                                        Age________________________
Athletes directions: Please review all questions with your parent or guardian and answer them to the best of your knowledge.
 
Yes No Don't 
Know
      1. Has anyone in the athlete's family (grandmother, mother, father, brother, sister, aunt, uncle) died suddenly before the age of 50 years?
      2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness:
      3. Does the athlete have asthma (Wheezing), hay fever, or coughing spells after exercise?
      4.  Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?
      5.  Does the athlete have a history of a concussion (getting knocked out)?
      6.  Has the athlete ever suffered a heat related illness (heat stroke)?
      7.  Does the athlete have anything he or she wants to discuss with the physician?
      8.  Does the athlete have a chronic illness or see a physician?
      9.  Does the athlete take any medicine?
      10. Is the athlete allergic to any medications or bee stings?
      11. Does the athlete have only one of any paired organ (eyes, ears, kidneys, testicles, ovaries, etc.)?
      12. Does the athlete wear glasses or contact lenses?
      13.  will the athlete wear orthodontic appliances during sports?
Elaborate on any positive answers:
 
 

I have answered and reviewed the questions above, and give permission for release of information on this form for confidential use in meeting my child" health and educational needs in school.

Signature of Parent or Guardian:_________________________________    Date:__________________________

Note:    the completed physical exam form must be in the school nurse's office before a student may participate in any school sponsored clinic, try-out, or practice for interscholastic sports.
 
 
 
 
 
 
 

School:____________________________________
Student Name:__________________________ Grade:_________  Date of Birth_______________________________

PHYSICAL EXAMINATION*
1.     HT____________ WT______________ BP______________ P______________
2.    Musculoskeletal examination (Record laxity, weakness, instability, decreased ROM -- if abnormal)
Normal Abnormal Description of abnormal findings
    A.Knee
    B. Ankle  
    C. Shoulder  
    D. Other Joints  
    E. Alignment problems 
(e.g. leg length, Q angle)		  
    F. Scoliosis  
    G. Feet  
    H. Estimate of strength  
    I. Estimate of flexibility
3. Cardiovascular Examination:

4. Other examination (if indicated by history):

ASSESSMENT  (check one)
5.    A. ___ No problems identified
        B.___ Other

RECOMMENDATIONS (check one)
6.     A. ___ Unlimited
        B. ___ Limited to specific sports:____________________________________________
        C. ___ Deferred until: ____________________________________________________
                    (e.g. rehabilitation, recheck, consultation, laboratory tests, etc.)

REEXAMINE (check one)
7.    A. ___ Yearly and after any injury that limits participation for longer than one (1) week
        B. ___ Other: ___________________________________________________________

DATE OF LAST TETANUS BOOSTER (MUST BE WITHIN 10 YEARS) ______________

Physician Signature _____________________________

Date of Examination ______________
Physician Name _______________________________

Physician Phone _________________
*The use of this form, and the results of this physical examination, are for the sole purpose of determining medical eligibility in Region 15 School sports programs and may not be used to determine medical eligibility for any other program.