PARTICIPATION

PHYSICAL EXAM FORM GRAND COULEE DAM SCHOOL DISTRICT

Name____________________________________________________Date______________________________________________

Address____________________________________________________________________________________________________

Phone____________________________________________________Birthdate____________________________Sex___________

Health Care Provider________________________________________Health Care Phone__________________________________

Sports____________________________________________________Grade____________________________________________

Notify in Emergency________________________________________Emergency Phone__________________________________

Alternate Emergency Name___________________________________Alternate Emergency Phone__________________________

__________________________________________________________________________________________________________

Medications (taken regularly)________________________________ Allergies: Student must return

to the school business

________________________________________________________ Medicine____________ office before practicing

or competing.

Last Tetanus shot__________(year) Bee Sting___________

__________________________________________________________________________________________________________

History

Explain “Yes” answers below: Yes No

1. Have you had a medical problem or injury since your last evaluation? ÿ ÿ

2. Have you ever been in the hospital or had an operation? ÿ ÿ

3. Have you ever been dizzy or passed out during or after exercise? ÿ ÿ

4. Have you ever had chest pain during or after exercise? ÿ ÿ

5. Have you ever had high blood pressure, a heart murmur, or irregular heartbeats? ÿ ÿ

6. Has anyone in your family died of heart problems or a sudden death before age 50? ÿ ÿ

7. Have you ever been knocked out or unconscious, had a head injury, or a seizure? ÿ ÿ

8. Have you ever had a “stinger,” “burner,” or pinched nerve? ÿ ÿ

9. Have you ever had muscle cramps, heat exhaustion, or heat stroke? ÿ ÿ

10. Do you have trouble breathing or do you cough during or after activity? ÿ ÿ

11. Have you ever had asthma, diabetes, mono, or other medical problems? ÿ ÿ

12. Are you missing an eye, kidney, or testicle? ÿ ÿ

13. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guard, etc.)? ÿ ÿ

14. Have you ever had a sprain, strain, dislocation, stress fracture, joint swelling, or broken bone? ÿ ÿ

___neck ___back ___shoulder ___elbow ___wrist ___hand

___hip ___thigh ___knee ___shin/calf ___ankle ___foot

15. Are you satisfied with your weight? ÿ ÿ

16. At what age was your first menstrual period?_______ Do you have at least eight periods in a year? ÿ ÿ

Please explain “Yes” answers: ________________________________________________________________________________

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Parent/Guardian: (Please read and sign)

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

I approve of my child’s participation in the Grand Coulee Dam School District athletic program, and I give permission for my child to receive a physical examination.

Date__________________________Parent/Guardian Signature______________________________________

PHYSICAL EXAMINATION

Name________________________________________________________________Age_______Date_________________________

____________________________________________________________________________________________________________

Height__________ Weight_____________ B/P_____/____ Pulse____________

____________________________________________________________________________________________________________

Normal Abnormal Findings Initials

____________________________________________________________________________________________________________

HEENT_____________________________________________________________________________________________________

Pupils Equal

Heart

Pulses

Lungs

Abdominal

Testicles/Hernia

Musculoskeletal (Symmetry/ROM/Strength/Flexibility

Neck

Back

Shoulder

Elbow

Wrist

Hand

Hip

Knee R MCL R ACL

L MCL L ACL

Ankle R ANT DRAWER

L ANT DRAWER

Foot

q No restriction for sports participation.

q Clearance withheld pending attached verification of rehabilitation/evaluation for:___________________________________

________________________________________________________________________________________________________

q Limited Participation. Not cleared for the following types of sports: _____________________________________________

________________________________________________________________________________________________________

Recommendations_____________________________________________________________________________________________

____________________________________________________________________________________________________________

Examiners Signature_________________________________Date____________________Phone_____________________________

Print Name and Address________________________________________________________________________________________