Sports Physical Fitness Information

Please fill the form below

Step 1

Step 2

Step 3

Candidate Name:

First Name

Last Name

Gender:

Male
Female

Date of Birth:

Address:

Address Line1

Address Line2

Land Mark

City

State

Country

Zip Code

Dad’s Name:

Mob No.:

Mom’s Name:

Mob No.:

Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc.::

Emergency Contact Person:

Medical History

Athletes and parents: This health record is a critical element in the determination of an athlete’s risk of injury in sports. Please take the time to read and answer all questions before seeing a physician for the athlete’s physical examination:


	YES	NO	Don’t Know
1. Has anyone in the athlete’s family (grandparents, mother, father, brother, sister, aunt, uncle) died suddenly before age 50?
2. Has the athlete ever stopped exercising because of dizziness or passed out during exercise?
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. Does the athlete have a history of concussion (getting knocked out)?
6. Has the athlete ever suffered a heat-related illness (heat stroke)?
7. Does the athlete have a chronic illness or see a doctor regularly for any particular problem?
8. Does the athlete take any medication(s)?
9. Is the athlete allergic to any medications or bee stings?
10. Does the athlete have only one of any paired organs? (Eyes, ears, kidneys, testicles, ovaries)

Please give details on any “YES” answer from the above health history. :

PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN

Height:

Weight:

Pulse:

Blood Pressure:

Please Print/ Stamp

Physician’s Members Name:

Mob No.:

Street Address:

City, State, Zip Code:

Signature:

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Medical History

Athletes and parents: This health record is a critical element in the determination of an athlete’s risk of injury in sports. Please take the time to read and answer all questions before seeing a physician for the athlete’s physical examination:

PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN

Please Print/ Stamp