Microsoft Word - Physical Form 08-09

MADERA UNIFIED SCHOOL DISTRICT

FAMILY HISTORY AND PHYSICAL FORM

PHYSICAL EXAMINATION

LIABILITY WAIVER: I agree to indemnify and hold the physician named below harmless against responsibility for injuries

or illness incurred by my student-athlete while participating in athletics.

Parent/Guardian Signature: __________________________________________ Date: __________________

BP ____/____ (_____/____/____/____) Urine ______________ Pulse _______________

All students participating in athletics must have a physical examination. I hereby certify that I have examined

_________________________________________ and found him/her to be physically fit to engage in sports.

STUDENT’S NAME

Notes:

_________________________________________________________________________________________________

Physician’s Signature: _________________________________________ Date: _________________



1. Have you had a medical illness or injury since your last check up or sports

physical? YES NO

Do you have an ongoing or chronic illness? YES NO

2. Have you ever been hospitalized overnight? YES NO

Have you ever had surgery? YES NO

3. Are you currently taking any prescription or nonprescription (over-the-

counter) medications or pills or using an inhaler? YES NO

Have you ever taken any supplements or vitamins to help you gain or lose

weight or improve your performance? YES NO

4. Do you have any allergies (for example, to pollen, medicine, food, or

stinging insects? YES NO

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

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

Have you ever been dizzy during or after exercise? YES NO

Have you ever had chest pain during or after exercise? YES NO

Do you get tired more quickly than your friends do during exercise? YES NO

Have you ever had racing of your heart or skipped heartbeats? YES NO

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

Has any family member or relative died of heart problems or of sudden

death before age 50? YES NO

Have you had a severe viral infection (for example, myocarditis or

mononucleosis) within the last month? YES NO

Has a physician ever denied or restricted your participation in sports for any

heart problems? YES NO

6. Do you have any current skin problems (for example, itching, rashes,

acne, warts, fungus, or blisters? YES NO

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

Have you ever been knocked out, become unconscious, or lost your

memory? YES NO

Have you ever had a seizure? YES NO

Do you have frequent or severe headaches? YES NO

Have you ever had numbness or tingling in your arms, hands, legs, or feet? YES NO

Have you ever had a stinger, burner, or pinched nerve? YES NO

8. Have you ever become ill from exercising in the heat? YES NO

9. Do you cough, wheeze, or have trouble breathing during or after activity? YES NO

Do you have asthma? YES NO

Do you have seasonal allergies that require medical treatment? YES NO



10. Do you use any special protective or corrective equipment or devices that

aren’t usually used for your sport or position (for example, knee brace, special

neck roll, foot orthotics, retainer on your teeth, hearing aid)? YES NO

11. Have you had any problems with your eyes or vision? YES NO

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

12. Have you ever had a sprain, strain, or swelling after injury? YES NO

Have you broken or fractured any bones or dislocated any joints? YES NO

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

tendons, bones or joints? YES NO

If yes, circle appropriately and explain below.

Head Elbow Hip

Neck Forearm Thigh

Back Wrist Knee

Chest Hand Shin/Calf

Shoulder Finger Ankle

Upper arm Foot

13. Do you want to weigh more or less than you do now? YES NO

Do you want to lose weight regularly to meet weight requirements for your sport?

YES NO

14. Do you feel stressed out? YES NO

15. Record the dates of your most recent immunizations (shots) for:

Tetanus _________________________ Measles _____________________

Hepatitus B ______________________ Chickenpox ___________________

FEMALES ONLY

16. When was your first menstrual period? _______________________________

When was your most recent menstrual period? ___________________________

How much time do you usually have from the start of one period to the start of

another? _________________________________________________________

How many periods have you had in the last year? _________________________

What was the longest time between periods in the last year? _________________

Explain “YES” answers here:_________________________________________

______________________________________________________________________________

____________________________________________________________

Student’s Name ____________________________________________________________________ ID # ______________________

LAST NAME FIRST NAME

What school did you attend last year? _______________________________ Grade _____Age _____ Date of Birth ____/_____/_____

Address ___________________________________________________________________________ Phone ____________________

_____________________________

SPORT

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

SIGNED: ____________________________________ DATE: _______ SIGNED: _____________________________________ DATE: __________

(Parent or legal guardian) (Student)

CONSENT FORM

PARENTAL PERMISSION: I hereby give my consent for __________________________ to engage in approved athletic

STUDENT’S NAME

activities, except those prohibited by the examining physician. I also give my consent for my child to travel with a

representative of the school district on interscholastic athletic trips. In the event this student is injured, the school district

official is hereby granted my permission to administer first aid and to secure medical treatment.

WARNING: PARTICIPATION IN ATHLETICS MAY RESULT IN SEVERE INJURY, INCLUDING PARALYSIS AND

DEATH. CHANGES IN RULES, IMPROVED CONDITIONING PROGRAMS, BETTER MEDICAL COVERAGE AND

IMPROVEMENTS IN EQUIPMENT HAVE REDUCED THESE RISKS BUT IT IS IMPOSSIBLE TO TOTALLY ELIMINATE

SUCH OCCURRENCES IN ATHLETICS.

Parent/Guardian Signature ________________________________________ Date: _____________________

INSURANCE STATEMENT: Under state law, school districts are required to ensure that all members of school athletic

teams have accidental injury insurance that covers medical and hospital expenses. Students must have insurance before

they are allowed to practice and participate in athletic programs. This insurance requirement can be met by the school

district offering insurance or other health benefits that cover medical and hospital expenses.

Some pupils may qualify to enroll in no-cost local, state, or federally sponsored health insurance programs. Information

about these programs may be obtained by calling Healthy Families at 1-800-880-5305.

California school law (Education Code 32220-24) requires every member of an athletic team to have bodily injury

insurance providing at least $1500 of scheduled medical and hospital benefits. The Madera Unified School District makes

available upon request insurance through a private insurance company for all students which will meet the education code

insurance requirements.

Parent/Guardian Signature ____________________________________________ Date _________________

(PLEASE COMPLETE INSURANCE INFORMATION BEFORE SIGNING)

ACKNOWLEDGEMENT:

 I/We, the parent/guardian and student-athlete have received, read and understand the MUSD Student & Parent

Guardian Athletic Handbook and acknowledge that violations of any policies may result in disciplinary

consequences while participating in interscholastic athletics, regardless of context, site or jurisdiction.

 I/We understand and agree that we are financially responsible for any items lost, stolen or damaged by my child.

I/We agree to attend a pre-season parent meeting.

 I/We recognize that under CIF Bylaw 200.D, there could be penalties for false or fraudulent information. I/We also

understand that the MUSD policy regarding the use of illegal drugs will be enforced for any violations of these

rules.

Student Signature _________________________________________ Date ________________

Parent/Guardian Signature _________________________________ Date ________________

NOTIFICATION AND DIRECTORY INFORMATION: If you do not object to the Athletic Director’s office releasing your

child’s name or other pertinent information to the news media, interested schools, parent-teacher associations, interested

employers and similar parties, please sign the YES line below. If you do object, please sign the NO line.

______________________________________ _______________________________________

Yes, it is permissible to release my child’s name No, I do not want my child’s name released

 I have Medi-Cal coverage: No _____ Yes _______ Card # __________________________________________________

 I have private medical insurance coverage: No ______ Yes ______ Name of company __________________________

 I am purchasing the private insurance that is being made available by MUSD: No ______ Yes ______ ***

*** This insurance must be paid for before a student is allowed to participate

 I hereby guarantee to keep medical insurance coverage in force, which meets or exceeds legal requirements for the

entire duration that my child participates in athletics.