Athletic Physical Form

Gender *

1. Have athlete had a medical illness or injury since last check up or sports physical ? *

2. Have athlete been hospitalized overnight in the past year ?*

3. Does the athlete have asthma (wheezing), hay fever, or coughing spells after exercise?

4. Has the athlete ever had a broken bone, had to wear a cast, or had an injury to any joint? *

5. Are you, the athlete, worried about any problem or condition at this time? *

6. Is the athlete allergic to any medications or bee stings? *

7. Has the athlete ever suffered a heat-related illness (heat stroke)?*

8. Does the athlete have only one of any paired organs? (Eyes, ears, kidneys, testicles, ovaries) *

Declaration*

An individual answering in the affirmative to any question relating to a possible cardiovascular health issue, as identified on the form, should be restricted from further participation until the individual is examined and cleared by a physician, physician assistant, chiropractor, or nurse practitioner.

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