Cony Middle and High School

1) Student Name:

2) Sex:

3) Age:

4) Date of Birth

6) Personal Physician:

7) Address

8) Phone number

9) Sport:

10) Have you ever been hospitalized?

Explain the Yes answers below.

Yes

No

11) Have you ever had surgery?

Explain the Yes answers below.

Yes

No

12) Are you presently taking any medications?

Explain the Yes answers below.

Yes

No

13) Do you have any allergies? (medicine(s), bees, etc.)

Explain the Yes answers below.

Yes

No

14) Have you ever passed out during or after exercise?

Explain the Yes answers below.

Yes

No

15) Have you ever been dizzy during or after exercise?

Explain the Yes answers below.

Yes

No

16) Have you ever had chest pain during or after exercise?

Explain the Yes answers below.

Yes

No

17) Do you tire more quickly than your friends during exercise?

Explain the Yes answers below.

Yes

No

18) Have you ever had high blood pressure?

Explain the Yes answers below.

Yes

No

19) Have you ever been told that you have a heart murmur?

Explain the Yes answers below.

Yes

No

20) Have you ever had racing of your heart or skipped heart beats?

Explain the Yes answers below.

Yes

No

21) Has anyone in your family died of heart problems or a sudden death before the age of 50?

Explain the Yes answers below.

Yes

No

22) Do you have any skin problems? (itching, rashes, acne)

Explain the Yes answers below.

Yes

No

23) Have you ever had a head injury?

Explain the Yes answers below.

Yes

No

24) Have you ever been knocked out or unconscious?

Explain the Yes answers below.

Yes

No

25) Have you ever had a seizure?

Explain the Yes answers below.

Yes

No

26) Have you ever had a stinger, burner or pinched nerve?

Explain the Yes answers below.

Yes

No

27) Have you ever had heat or muscle cramps?

Explain the Yes answers below.

Yes

No

28) Have you ever been dizzy or passed out in the heat?

Explain the Yes answers below.

Yes

No

29) Do you have trouble breathing or do you cough during or after activity?

Explain the Yes answers below.

Yes

No

30) Do you use any special equipment? (pads, braces, neck rolls, mouth guard, eye guards, etc)

Explain the Yes answers below.

Yes

No

31) Have you ever had any problems with your eyes or vision?

Explain the Yes answers below.

Yes

No

33) Have you had any other medical problems? (infectious mononucleosis, diabetes, etc)

Explain the Yes answers below.

Yes

No

34) Have you had a medical problem or injury since your last evaluation?

Explain the Yes answers below.

Yes

No

35) If you answered YES to any of the above questions please explain further here: (optional)

36) When was your last tetanus shot?

37) When was your last measles immunization?

38) Signature of Athlete

I hereby state that to the best of my knowledge, my answers to the above questions are correct.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

39) Signature of Parent/Guardian

I hereby state that to the best of my knowledge, my answers to the above questions are correct.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

40) Today's Date

Cony Middle and High School

PRE-PARTICIPATION PHYSICAL EVALUATION

Pre-Participation Physical Evaluation