Central Kitsap School District

INITIAL PHYSICAL EXAMINATION FOR ATHLETIC COMPETITION

to be completed before entry into athletics

Name: ________________________________________________________ Visual Acuity: L 20/____________ R 20/_____________

Height: _______________________ Weight: ________________________ With/Without Correction

Contact Lenses (circle one) Y N

Blood Pressure (Sitting, Rt. Arm): ________________________________

Pulse: Resting pulse ___________________________________________

Lab*: Hct ______________________ Sickle Cell __________________

Urinalysis*: Protein _________ Sugar _________ Blood _________

*Optional (Urinalysis needs parent authorization.)

_

General Appearance/Somatotype: ________________________________ Abdomen: ________________________________________

Eyes: E.O.M.__________________________________________________ Genitalia: _________________________  Not examined

Pupils: _______________________________________________________ Skin: ____________________________________________

Ears/Nose/Throat: _____________________________________________

Other Remarks: ___________________________________

Dental/Braces: ________________________________________________ _________________________________________________

_________________________________________________

Lymph Nodes: ________________________________________________

Strength:_________________________________________

Cardiac: Murmur: Yes _______ No ________ _________________________________________________

Pulse: Regular _______ Irregular _________ _________________________________________________

Respiratory: __________________________________________________ Flexibility: _______________________________________

_________________________________________________

Posture/Neck/Back/Scoliosis: ___________________________________ _________________________________________________

_____________________________________________________________

_____________________________________________________________ General Conditioning: _____________________________

Upper Extremities: ___________________________________________ _________________________________________________

_____________________________________________________________ _________________________________________________

_____________________________________________________________

Lower Extremities: ____________________________________________

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DISPOSITION AND RECOMMENDATIONS (use back of form for additional information)

DIAGNOSIS OR PROBLEM TREATMENT RECOMMENDATIONS

1) ___________________________________________________________ _________________________________________________

2) ___________________________________________________________ _________________________________________________

3) ___________________________________________________________ _________________________________________________

_________________________________________________________________________________________________________________

DISPOSITION: ____________ 1) Unrestricted activity in high school sports grades 9-12

____________ 2) Unrestricted activity in any sport grades 7-8

____________ 3) Unrestricted activity in all sports except ________________________________________

____________ 4) No participation until ________________________________________________________

____________ 5) Conditional participation, limited to ____________________________________________

____________ 6) No participation in any sport

_______________________ ____________________________________________________ _________________________________

Date Doctor’s Signature Phone

HEALTH HISTORY FORM FOR ATHLETIC COMPETITION

to be completed before visit to health professional

Date: _______________________ School: ________________________________________________________

Student’s Name: _______________________________________________ Notify in emergency: ____________________________________________

Address: ______________________________________________________ Address: ______________________________________________________

Phone: ________________________________________________________ Phone: ________________________________________________________

Birth Date: ____________________ Age:__________ Grade: __________ Family Doctor: _________________________________________________

Date of last tetanus booster: ______________________________________ Phone: ________________________________________________________

(Circle One) Left Handed Right Handed

PLEASE CHECK ONE ANSWER YES NO YES NO

Has anyone in your family under age 50 died ............................................................................. Have you had or do you now have

suddenly?........................................................... other joint trouble?.........................................

Have you had or do you now have Arthritis?..........................................................

brain concussion (head injury)?...................... Scoliosis?.........................................................

Tendency to lose consciousness (faint)?........ Have you had or do you now have diabetes

Skull Fracture?................................................. (high sugar in blood or urine)?.....................

Convulsions or epilepsy?................................. Tendency to bleed or bruise easily?.............

Neck injury?...................................................... Anemia (“tired blood”)?.................................

Headaches?........................................................ Mononucleosis?...............................................

Liver disease?..................................................

Have you had or do you now have very bad

(impaired) vision in one eye?.........................

Temporary loss of vision?................................ Have you had or do you now have Asthma

Do you wear glasses or contact lenses? ......... (wheezing)?......................................................

Hay fever?........................................................

Have you had or do you now have.................... Chest tightness & cough following running?

hearing loss?...................................................... Hives or rash?..................................................

Perforated ear drum?........................................ Bee sting reactions (allergy)?........................

Discharge from ear (recurrent infections)?... Reaction to medicine (allergy)?....................

Sinus infections?..............................................

Broken nose? .................................................... Do you:

Dental Plate (dentures)?.................................. Use alcohol or drugs?......................................

Removable retainer?......................................... Smoke or chew?..............................................

Take any medicine regularly?......................

Have you had or do you now have ................... If yes, name __________________________

a hernia?............................................................

Kidney problems (or absence of)?................... Take medicine for emergency use?................

Boys: Problem with testicles?......................... If yes, name __________________________

Girls: Menstrual problems?...........................

Age of onset of menstruation ______

Breast lumps or tenderness?............... Have you had or do you now have heart

trouble or murmur?........................................

Have you had or do you now have High blood pressure?........................................

broken bones/cast?............................................ Persistent cough?..............................................

Joint dislocation?.............................................. Dizziness or faintness with heat?...................

Shoulder injury or recurrent pain?................ Cold sores?.........................................................

Elbow injury or recurrent pain?...................... Fungus infection?.............................................

Back injury or frequent backaches?............... Athlete’s foot?...................................................

Knee injury, recurrent pain or swelling?...... Recurrent boils (skin infection)?....................

Shin splints or recurring leg pain?................

Ankle injury or recurrent pain?..................... Have you ever had any other injuries or illness

Foot problems?.................................................. that caused you to miss a game or practice?

ADDITIONAL HISTORY INFORMATION_______________________

I HAVE READ THIS FORM. ALL INFORMATION IS ACCURATE.

Parent Signature Required

_____________________________________________________________

PHYSICIAN’S REMARKS ____________________________________

_____________________________________________________________

_____________________________________________________________ Use back of form to provide further information

Physician’s Signature