Nlercer Island High School PHYSIC.\L EXAIIIN*\TION

Nlercer Island High School PHYSIC.\L EXAIIIN*\TION

Nlercer Island High School PHYSIC.\L EXAIIIN*\TION
'fo be completed by a physician lvith signature for sports ctetrance once cnch school ye:rr
)Iercer Islnnrl School District requires n physical extrm every two yer13 for sports participation
I)rlte:
I,{*rnr:
tlP:
Weight:
Height:
l"
Vision: fr"2W
Comected:
201
Pulse:
YN
Pupils
,-tbnorm*l ltintlin
Crrdiopulrnanary
,\btlominal
e
nitalia
Iusculoskeletal
C learance:
A.
Cleared
B. Cleared
after completing evaluation/rehabilitation for:
C. Not Cleared
for:
Collision
o
Contact
o
Activity level
o
Strenuous
lvloderately strenuous
Non strenuous
Due to:
Recomrnendation:
Name of Physicirn: (PLEASE PRtN"f)
Ilhone:
Ilate of Exam:
Physician's Signltu re:
Date of S ignatu re:
Fpr otljce, use orrly
Exam Ex
Clearance ll.xn:
t6
Nlercer lsland ttigh School ,I'IHLETIC IlEr\L'fH FOR]I
"fo be tilled out by the studentlparent
S
Birth Date
tudent
Grrde
Cender
Wk. l]hone
Ihn. Ilhone
r\delress
['hy siciir*'s Narne (Plcase Print)
Phy
sic
[]hone
ian's r\tltlress
f)ute of last 'letimus Immunizatkln']
lixplain "Yes"
I
.
Date
of last Measles [rnmunizttion'l
rtnsrvers belorv
Ovcrnight hospitalizations, operutions or surgery'/ Dates
No
Ycs
o
o
2,.
Are you presently taking any nredication or pills?
o
o
3.
Do you have any allergies (medicine, bees or other stinging insects?)
o
o
4.
Have you ever passed out during or atter exercise?
o
o
o
o
o
o
I
[ave you ever been dizzy during or alter exercise?
Do you tire rnore quickly than your friends during exercise?
F{ave you ever had high blood pre ssure?
f"lave you ever been told that you have a heart murmur'/
[Iave you ever had racing of your heart or skipped heartbeats?
Anyone under 50 yrs old in the fhmily die of heart problerns?
5.
Do you have any skin problems?
6.
I-lave you ever had a head injury?
o
0
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
7.
Have you ever had heat or muscle cramps?
8.
Do you have trouble breathing or do you cough during or ufter activity?
o
o
o
o
o
o
0
9.
Do you use any special equipment (pads, braces, mouth guard, etc?
o
o
I-lave you had any problems rvith your eyes or vision?
o
o
o
Flave you ever been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had a stinger, burner or pinched nerve?
l-lave you ever been dizzy or passed out in the heat?
10.
Do you lvear glasses or contacts or protective eye or vision?
11.
Have you ever sprained/strained, dislocated, fractured, broken or had
repeaterJ srvelling or other injuries
o [ lead
o
o Forearm
I
2.
o
["enrales
of any bones or joints?
Shoulder
qr Shi#calf
Only: I lave your
o
o
o Thigh
o lrleck
o Elbow
o Knee
o Ch*st
0 Brck
o Wrist
o z\nkle
o tlip
o l'fand
o lroot
menses begrrn?
Do tl'rey come lnore uften than $nce a rnonth?
[,ess
tlft*n than cvery
tr,vo nronths'/
Explain "Yes" *nsrvers to Questions l-12 above:
'l-he signature belorv indicates that a parent/guardian and the pnrticipating student acknorvledge
they have caretirlly read this fbrm and the above
infbrnratiorr is true.
S"ftlDEN'f
SIGNr[l'l,lRE:
DrYt'E:
D.I
I" F]
:
t5