Sacramento City Unified School District - SPORTS PHYSICAL EXAMINATION FORM
PART 1 (TO BE COMPLETED BY A PARENT OR LEGAL GUARDIAN)
LAST NAME
FIRST NAME
GRADE
BIRTHDATE
FALL SPORT
WINTER SPORT
SPRING SPORT
STUDENT ID NUMBER
HEALTH HISTORY (Must be Completed Prior to the Examination)
Yes No Has this student had any: Yes No Does this student:
1.
Chronic or recurrent illness?
16.
Wear eyeglasses or contact lenses?
2.
Illness lasting over 1 week?
17.
Wear dental bridges, braces or plates?
3.
Hospitalizations or Surgery?
18.
Take any medications? (List below):
4.
Nervous, psychiatric, or neurologic condition?
5.
Loss or nonfunctioning of organs (eye, kidney, Yes No Is there any history of:
liver, testicle) or glands?
6.
Allergies (medicines, insect bites, food)?
19.
Injuries requiring medical care or treatment?
7.
Problems with heart or blood pressure?
20.
Neck or back pain or injury?
8.
Chest pain or severe shortness of breath with
21.
Knee pain or injury?
exercise? 22.
Shoulder or elbow pain or injury?
9.
Dizziness or fainting with exercise?
23.
Ankle pain or injury?
10.
Fainting, bad headaches or convulsions?
24.
Other joint pain or injury?
11.
Concussion or loss of consciousness?
25.
Broken bones (fractures)?
12.
Heat exhaustion, heatstroke, or other problems Yes No Further history:
with heat? 26. Birth defects (corrected or not)?
13.
Racing heart, skipped, irregular heartbeats, or
27.
Death of parent or grandparent less than 40
heart murmur? years of age due to medical cause or condition?
14.
Seizures?
28.
Parent or grandparent requiring treatment for
15.
Severe or repeated instances of muscle cramps? heart condition less than 50 years of age
Date of last known tetanus (lockjaw) shot: 29. Been seen by a physician on an emergency or
Date of last complete physical examination: urgent basis in the last 12-months?
Explain all “YES” answers here along with any other fact or circumstance that should be disclosed prior to the examination (use
reverse of form if needed):
PARENT/GUARDIAN’S AUTHORIZATION: I authorize a physician or duly authorized and supervised physician’s assistant or nurse
practitioner to perform a Sports Physical Evaluation on the student. The information set forth above is complete and accurate and I know of no
reason why the student cannot fully and safely participate in the listed sports. I understand that this is solely a screening examination and that the
absence of any health conditions or concerns listed below does not mean that student is free from actual or potential harmful health conditions that
may cause the student injury or death while participating in sports. Any question or concern I may have regarding the student’s health or safety will
be referred to our personal physician or health care provider for review and evaluation.
PRINT NAME OF PARENT OR GUARDIAN
SIGNATURE OF PARENT OR GUARDIAN
ADDRESS
WORK PHONE
HOME PHONE
DATE
REGULAR PHYSICIAN’S NAME
OFFICE PHONE
PART 2 (TO BE COMPLETED BY THE EXAMINING
PHYSICIAN/PHYSICIAN’S ASSISTANT/NURSE PRACTITIONER)
NORMAL
ABNORMAL (Describe)
Eyes/Ears/Nose/Throat
Height:
Skin
Weight:
Heart
Pulse:
After Ex:
Abdomen
BP:
Genital/hernia (males)
Recommendation:
Unlimited participation
Musculoskeletal:
a. Neck/Spine/Shoulders/Back
b. Arms/Hands/Fingers
Limited participation/specific
sports, events or activities
Clearance withheld pending
further testing/evaluation
No athletic participation
One of the above MUST be checked.
c. Hips/Thighs/Knees/Legs
d. Feet/Ankles
Neurologic Screening Exam (NSE)
Comments:
PRINT NAME OF PHYSICIAN (M.D., D.O., P.A, or N.P. only)
PHYSICIAN’S SIGNATURE
DATE
