HEALTH QUESTIONNAIRE AND PHYSICAL EXAMINATION

This questionnaire must be completed, signed by both parent/guardian and student, and returned to school before the student can participate in any sports season. This questionnaire (or a physical form from the physician’s office) needs to filled out and signed by the physician only if the student needs a physical examination.

___________________________________________ _____________________

Student’s Name Date

______________________________________________________________________

Address

_____________________ ___________________________________________

Phone Signature of Parent/Guardian

Student’s Birthdate____________ Sex: M F Grade________________

Date of last physical exam __________ Date of last tetanus booster shot:__________

Name of physician:___________________________________ Phone:_____________

A complete physical exam by a physician is required every two years in order to participate in the athletic programs. The student will participate in the following athletic activities:

Cross Country Soccer Basketball

Baseball Softball Cheerleading

During the past two years, has the student been told you could not participate in a sport? YES NO

Has the student ever suffered from a blow to the head that caused unconsciousness or loss of memory? YES NO

Has the student had a fracture or dislocation in the past two years? YES NO

Has the student had a knee or ankle sprain in the past two years? YES NO

Has the student had any other injuries in the past two years? YES NO

Is the student under a physician’s care now for any health concerns? YES NO

Does the student take any medication regularly? If YES what is the medication, how often is taken, why is it taken, and if a reaction what should be expected? YES NO

Has the student had an illness lasting longer than one week in the last six months? YES NO

Does the student have any allergies? If YES what are they, and is medication taken for them? YES NO