HOLY SPIRIT SCHOOL

HEALTH HISTORY FORM

SPORTS PHYSICAL

 

STUDENT NAME: ______________________________________________________________

 

ADDRESS: ____________________________________________________________________

 

TELEPHONE:   _______________________               DATE OF BIRTH:    __________________

 

TO BE COMPLETED BY EXAMINING PHYSICIAN

 

DISEASE HISTORY (PLEASE CHECK ANY THAT APPLY)

 

Allergies			Asthma
Drug Sensitivities			Convulsive Dis
Hepatitis			Diabetes
Neromusc Dis			Heart Disease
Obesity			Rheumatic Fever
High Blood Pressure			Strep Infection
Mononucleosis			Kidney Disease
Orthopedic Problems			Heart Murmur

 

If you answered yes to any of the above, please explain and note any restrictions:

 

______________________________________________________________________________

 

______________________________________________________________________________

 

1. Date of last DPT Booster:   ______________________

 

2. Any serious illness or injury in the last four year? ______

 

    If yes, specify:   ________________________________________________________________

 

3. Is the child receiving any medication?   Yes _____      No _____

 

4. If there is any chronic condition the school should be aware of, please specifiy:

 

    ____________________________________________________________________________

 

    ____________________________________________________________________________

 

    ____________________________________________________________________________

 

HOLY SPIRIT SCHOOL

HEALTH HISTORY FORM

SPORTS PHYSICAL

 

Height _______________                 Weight   ______________           Blood Pressure    _________

 

Nose ________________                 Throat _______________           Teeth-Mouth   ___________

 

Heart ________________                 Lungs   _______________           Abdomen ______________

 

Thyroid ______________                 Hernia _______________           Lymph Glands   __________

 

Genito-Urinary    _______________      Skin  (non comm.) __________________

 

Orthopedic Structural    __________      Posture _______________   Feet ______________

 

Nervous System _______________      General Appearance ______________________________

 

May the child participate in active sports?     Yes _____    No _____

 

I have checked this student for scoliosis and have found him/her:

 

(Circle One):     Negative                         Positive

 

If Positive, has referral been made?     _________________________________________________

 

I have examined the following boy/girl and found him/her to be in good physical condition to participate in the sports program (ie. Cheerleading, Volleyball, Basketball) at their school.

 

Physician’s Signature     ___________________________________

 

Date of Examination      ___________________________________

 

 

Physician’s Stamp