New Lake Football and Cheer

PHYSICAL FORM - Athletic Competition Health Screening Form

NAME: _____________________________ ADDRESS ______________________________ CITY____________

Zip _____ PHONE _______ SCHOOL: _______________ GRADE: __ Date Of Birth ________AGE: __ Sex__

Parent Name: ____________________________ Family Physician ____________________ Phone ______________

HEALTH HISTORY

Vitals	Satisfactory Yes No	Physical Evaluation Comments	Recommend Follow Up
Ht. Wt. BP GENERAL HEAD EYES ENT DENTAL CHEST HEART ABDOMEN GENITALIA SKIN EXTREMITIES BACK/NECK ALLERGY		ACUITY (R & L)

Parent or Guardian Answer "Yes" or "No" Only Yes No

Chronic/Recurrent illness? Hospitalization? Surgery Other Than Tonsils? Injuries Treated by Physician? Current Medications? Organs Missing?

Heat Exhaustion/Stroke? Dizziness, Fainting: Convulsions and / or Headaches? Knocked Out? Concussion?

Wear Glasses or Contacts? Hearing Defects? Dental Appliances? Bridge/Brace/Cap/Plate?

Cough/Pain? Problems with Blood Pressure, Heart or Murmurs? Problems with Liver, Spleen or Kidney? Hernia? Recurrent Skin Disease?

Bone / Joint Injury? Sprain / Dislocation? Injury that caused a missed Practice / Event?

Allergic to Medications? Name: Tetanus / Booster in the last 10 years?

YES

The above information is currently correct to the Best of my knowledge.

__________________________________________ Date _________________ (Signature of Parent or Guardian)