Current Grade 9 10 11 12
CENTER UNIFIED SCHOOL DISTRICT
Athletics Health Screening Examination Record
___________________________________ _______________ _______________
Student Name Date of Birth Telephone #
Age: _________ Gender: _________ Height: _________ Weight: _________
Health History
(to be completed and signed by parent/guardian)
Has your child ever had or does he/she now have any of the following?
Yes No (Please explain any yes answers)
1. Chronic or recurrent illnesses
2. Illnesses lasting more than a week
3. Hospitalizations
4. Surgery, other than tonsillectomy
5. Problem with blood pressure or heart
6. Dizziness, fainting or frequent headaches
7. Ever been knocked out or had a concussion
or lost memory
8. Neck/back injury or surgery, numbness or tingling in arms, hands, legs or feet
_________________________________________________________________
9. A stinger, burner or pinched nerve? _________
10. Knee, ankle injury or surgery
11. Other joint sprains or dislocation, pain or swelling
12. Broken bones (fractures)
__________
13. Epilepsy or seizure disorder
14. Asthma or shortness of breath
15. Diabetes
16. Illness from exercising in the heat ________
17. Nervous disorder or mental illness
18. Currently taking any medications
19. Allergic to any medications (aspirin, penicillin, etc.) or bee stings
20. Wear eyeglasses or contact lenses _________
21. Wear dental appliances, othotics or prosthetic equipment
________
22. Desire to weigh more or less than current weight. Lose weight regularly to meet
weight requirements for sports ________________________________________
23. Stressed out feeling _________________________________________________
Please use this space to further explain the above answers or for additional information:
________________________________________________
________________________________________________
________________________________________________
Health Screening Examination
(to be completed and signed by a physician)
Pulse Rate: Blood Pressure:
Normal
Abnormal
Comments
Eyes/Ears/Nose/Throat
Lymph nodes
Heart
Lungs
Abdomen
Genitalia/Hernia (males only)
Skin
Neck/Spine
Arms/Shoulders/Elbows
Wrists/Hands
Legs/Hips/Thighs/Knees
Ankles/Feet
Based on this history and physical exam the following ABNORMALITIES were found
and need further evaluation before clearance for competitive athletics
:
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
Recommendations:
CLEARED - There were no history or physical findings on this exam which would
prohibit this student from participating in competitive athletics.
This student should have the above health problems evaluated or treated PRIOR
to participating in competitive athletics.
Parent/Guardian Permission and Release
I declare that the above information is correct to the best of my knowledge. I understand
this is a screening examination to determine if any obvious medical problems exist to
prevent my child from participating in school athletic events. This examination is not a
complete medical examination. You should contact your family physician for your
medical needs. If any medical problems are identified in this screening examination,
further examination and treatment should be obtained through your physician.
_
______________________________ ___________
Parent/Guardian Si
g
nature Date
This student has health problems which would PROHIBIT him or her from
participating in competitive athletics.
Physician Name (print/type) Phone
Physician Signature Date
D191d Rev. 05/10
ALL Physicals MUST have an official stamp from your doctors office !
**REMINDER** ALL Physicals MUST have an official stamp from your doctors office !
