1600 MLK Jr. Blvd   Dalton, GA 30720   706-277-1198

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CHS Sports Physical Form

Child’s name _____________________________________ Birthdate _________________ Date ____________

Parents, please fill out information below before child is examined, thank you.
Medical History:

  1. Illnesses or injury: ____________________________________________________________
  2. Hospitalization or surgery: ______________________________________________________
  3. Medications (including performance enhancers): ___________________________________________________________________________
  4. Special or protective equipment used in sports: ___________________________________________________________________________

Cardiac :

  1. Any dizziness, passing out or chest pain during exercise: _______________
  2. History of high b/p or heart murmur: __________
  3. Family history of heart disease: _____________
  4. Previous history of disqualification or limited participation d/t cardiac problems: ___________

Respiratory :

  1. Asthma, coughing, wheezing, or dyspnea with exercise: ________________________

Orthopedic :

  1. Previous injuries that have limited sports participation: ___________________________________
  2. Injuries that have been associated with pain, swelling or needed medical intervention: _____________________________________________________________________________

Neurology :

  1. History of head injury or concussion: __________________
  2. Numbness or ringing in the extremities: ________________
  3. Severe headaches: ______________

Vision :                                                               Genitourinary:

  1. Visual problems: __________                     1. Age at Menarche: _________
  2. Corrective lenses: _________                     2. Last Period: _____________ Problems: ______________

Psychological :

  1. Weight control and body image: _______________________________
  2. Stresses a home or in school: _________________________________
  3. Use or abuse drugs or alcohol: ________________________________

 

Physical Exam:

Height ________ Weight ________ B/P _______ Heart Rate ________ Visual Acuity: Rt ______ Lt______

Pulses: __________________________________ Heart Rate & Rhythm ___________________________

Murmurs: + - ___________________________ Breath Sounds ___________________________________

Abdomen: ____________________________________________________________________________

Orthopedic Examination: _________________________________________________________________

Comments: ___________________________________________________________________________

                     ___________________________________________________________________________

 

Physician’s Certificate:

I hereby certify that ___________________________________________ has been examined by me and found physically fit to engage in school athletics.

Date: ___________ Healthcare Provider’s Signature: ______________________________________

 

Emergency Treatment and Information:

To all the parents: Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without parent’s consent unless a matter of life or death. It is requested that you complete the information below so that if your child requires a visit to the hospital while under the supervision of the school, this will allow the hospital to treat the injury.

 

Name ______________________________ Sport(s) ______________________________ Sex M___ F___

School ___________________________________ Grade _____ Age _____ Date of Birth ______________

Parent’s Name _________________________________________________________________________

Father’s S.S. # _____________________________ Mother’s S.S. # _______________________________

Work Address ____________________________________ _ Phone # _____________________________

Home Address ___________________________________ _   Phone # ____________________________

Another person to contact _________________________________________________________________

Relationship to student ___________________________________________________________________

Insurance Name ________________________________________________________________________

Policy and/or Group Numbers ______________________________________________________________

Allergies ______________________________________________________________________________

 

Consent Statement Authorizing Treatment:

Parent’s Signature: ________________________________________________________________

Student’s Signature (if over age 18): _________________________________________________

 

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Parent’s Consent

I hereby give my consent for my child _______________________________________________________ to

represent (school name) __________________________________________________________________

on the sport(s) of _______________________________________________________________________

Date ____________________   Parent’s Signature ___________________________________________

 

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