EmailMeForm
Medical Evaluation Form
Student Name
*
First
Last
Grade
School
Sex
Male
Female
Date of Birth
MM
/
DD
/
YYYY
Phone
###
-
###
-
####
Sport
*
Baseball
Football
Cheer
Drum Line
Soccer
Softball
Volleyball
Golf
Basketball
Parent / Guardian Name
First
Last
Parent / Guardian Employer
Parent / Guardian Work Phone
###
-
###
-
####
Insurance Company
Policy Number
Family Doctor
PART II: MEDICAL HISTORY
To be filled out by parent or guardian
Has or Does this athlete
1. Have a medical problem or injury since his/her last evaluation
*
Please select
YES
NO
2. Ever not been allowed to participate in sports for a medical reason?
*
Please select
YES
NO
3. Ever been hospitalized?
*
Please select
YES
NO
4. Ever had surgery?
*
Please select
YES
NO
5. Have any missing organs? (eye, kidney, testicle, etc.)
*
Please select
YES
NO
6. Presently take any medication?
*
Please select
YES
NO
7. Have any allergies to medicine or insect bites?
*
Please select
YES
NO
8. Passed out during or after exercise?
*
Please select
YES
NO
9. Been dizzy or passed out during or after exercise?
*
Please select
YES
NO
10. Have chest pain during or after exercise?
*
Please select
YES
NO
11. Tire more quickly than his/her friends during exercise?
*
Please select
YES
NO
12. Have high blood pressure?
*
Please select
YES
NO
13. Been told he/she has a heart murmur?
*
Please select
YES
NO
14. Have racing of the heart or skipped heartbeats?
*
Please select
YES
NO
15. Have a family member that died of heart problems or sudden death before age 50?
*
Please select
YES
NO
16. Have any skin problems?
*
Please select
YES
NO
17. Ever had a head or neck injury?
*
Please select
YES
NO
18. Ever been knocked out or unconscious?
*
Please select
YES
NO
19. Ever had a seizure?
*
Please select
YES
NO
20. Ever had a stinger, burner or pinched nerve?
*
Please select
YES
NO
21. Ever had heat cramps?
*
Please select
YES
NO
22. Ever been dizzy or passed out in the heat?
*
Please select
YES
NO
23. Have trouble with breathing or coughing during or after activity?
*
Please select
YES
NO
24. Use any special equipment? (pads, braces, neck rolls, eye guards, kidney belt, etc.)
*
Please select
YES
NO
25. Have any problems with vision?
*
Please select
YES
NO
26. Wear glasses or contacts?
*
Please select
YES
NO
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