Shelburne Community School

Pre-participation Physical Evaluation

 

***PHYSICAL EXAMINATION DATE –________/_______/________***Must be within 2 years***

                                                                                   month        day         year

 

Name __________________________________________________      Date of Birth_____________________________________

 

Height __  __________Weight__      _____% Body Fat (optional) ___   ____ Pulse _____              _BP_ __/__ _(__ _/       , _ _/_ __)

 

Vision  R 20/   ____     L 20/ ___                  Corrected:  Y   N           Pupils:    Equal   ____  Unequal    ____

 

MEDICAL

Normal

Abnormal

Initials

Appearance

 

 

 

Eyes/Ears/Nose/Throat

 

 

 

Lymph Nodes

 

 

 

Heart

 

 

 

Pulses

 

 

 

Lungs

 

 

 

Abdomen

 

 

 

Genitalia (males only)

 

 

 

Skin

 

 

 

MUSCULOSKELETAL

Neck

 

 

 

Back

 

 

 

Shoulder/arm

 

 

 

Elbow/forearm

 

 

 

Wrist/hand

 

 

 

Hip/thigh

 

 

 

Knee

 

 

 

Leg/ankle

 

 

 

Foot

 

 

 

*station-based examination only

 

 

CLEARANCE

___    Cleared

___    Cleared after completing evaluation/rehabilitation for:

 

 

 

 

____  Not cleared for: ____________________Reason:______________________________________________________________

 

 

Recommendations:  __________________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

___________________________________________________________________________________________________________

 

Name of Physician (print/type) _______________________________________________________________Date _____________

 

Address _______________________________________________________________________Phone _______________________

 

Signature of Physician ______________________________________________________________________________, MD or DO

 

 

 

 

 

 

 

 

 

 

Updated: 7/2007

 

 

Shelburne Community School

Pre-participation Health Questionnaire For Interscholastic Sports

 

This form needs to be filled out one time each school year by student and parent.  If you are due for a Physical

Exam by a doctor, fill out this form and take it with you to the appointment.  Physical Exams are required within two years of the sports participation.

 

NAME _____________________________________________   SEX ___________  AGE ____________ DOB ________________

 

GRADE ______ SPORT(S) _________________________________________________ TODAY’S DATE ___________________

 

 

EXPLAIN “YES” ANSWERS BELOW

CIRCLE QUESTION IF YOU DON’T KNOW THE ANSWER

 

Has there been any major change in your health since your last check-up?  Hospitalization, surgery, illness or injury?                                                                                                                  YES                                         NO

 

Do you have an ongoing or chronic illness?                                                   YES                                         NO

 

Are you currently taking ANY medication?                                                         YES  (list)                                                NO

 

Do you have ANY allergies – medicine, pollen, food, sting insects?           YES  (list)                                               NO

 

Have you ever had a rash or hives develop during or after exercise?          YES                                         NO

 

Have you ever passed out during or after exercise?                                       YES                                         NO

 

Have you ever been told you have a heart murmur?                                      YES                                         NO

 

Do you have any skin problems?                                                                      YES                                         NO

 

Have you ever had a concussion or head injury?                                           YES                                         NO

 

Do you have frequent or severe headaches?                                                   YES                                         NO

                               

Do you have asthma?                                                                                          YES                                         NO

 

Do you use any special protective or corrective equipment or devices                                                                          (knee brace, retainer, hearing aid)?                                                                       YES  (explain)                        NO

 

Do you wear glasses, contacts, or protective eyewear?                                  YES                                         NO

 

Have you had any problems with pain or swelling in muscles, tendons,

bones or joints?                                                                                                      YES                                         NO

 

If yes, circle area and explain below:

 

                Head                       Elbow                      Finger                     Shin/Calf

                Neck                        Forearm                  Hip                          Ankle      

                Back                        Wrist                       thigh                        Foot

                Shoulder                  Hand                       Knee

 

Explain: ___________________________________________________________________________________________

 

               ___________________________________________________________________________________________

 

               ___________________________________________________________________________________________

 

                               ___________________________________________________________________________________________

 

                                 ___________________________________________________________________________________________

 

                                 ___________________________________________________________________________________________

               

 

I hearby state that, to the best of  my knowledge, my answers to the above questions are complete and correct.

 

 

Student  Signature  ____________________________Parent Signature ___________________________Date ________________

 

Preparticipation Health Questionnaire and Preparticipation Physical Evaluation Forms are required ONLY if a student intends to play INTERSCHOLASTIC sports…that is, games in which SCS competes against other schools. This fall, SCS wil have soccer, cross country and field hockey teams which will compete against other schools in the area.

 

Updated 7/2007