Transcription of Pre-participation Examination
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Pre-participation Examination
Pre-participation Examination To be completed by athlete or parent prior to Examination . Name School Year Last First Middle Address City/State Phone No. Birthdate Age Class Student ID No. Parent's Name Phone No. Address City/State HISTORY FORM. Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Food Stinging Insects Explain Yes answers below. Circle questions you don't know the answers to. GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports 26.
Pre-participation Examination PHYSICAL EXAMINATION FORM Name Last First Middle EXAMINATION Height Weight Male Female
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