Football Tryout Player Health Checklist
Player Name
Date of Birth
Emergency Contact Name
Emergency Contact Phone
Health Screening
Fever or chills recently
Cough/shortness of breath
Recent injury or illness
History of concussion
Asthma or breathing problems
Chest pain or heart condition
Recent hospitalization or surgery
Allergies (food, medication, etc.)
Other medical conditions
If yes to any above, please explain
Current Medications
Physician Information
Physician Name
Physician Phone
Parent/Guardian Signature
Date
Player Signature
Date