Amateur Boxing Pre-Participation Medical Assessment Form
A. Athlete Information
Full Name
Date of Birth
Sex
Address
Phone Number
Boxing Club
Coach Name
B. Medical History
Do you have or have you ever had:
Condition
Yes
No
Details
Heart problems
Asthma or breathing issues
Seizures/fainting/blackouts
Diabetes
Previous head injury/concussion
Other major illnesses/surgeries
Current Medications
Allergies
C. Physical Examination
Height (cm)
Weight (kg)
Blood Pressure
Vision (Left / Right)
Physical Examination Notes
D. Physician Clearance
Physician Name
Signature
Date of Examination
Clearance Notes