Sports Physical Medical History Form
Personal Information
Name
Date of Birth
Sex
Male
Female
Other
Grade
Address
Parent/Guardian Phone
Emergency Contact Name
Emergency Contact Phone
Medical History
Has the student ever had (check all that apply):
Asthma
Diabetes
Concussion
Seizures
Heart Problems
Broken Bones
Allergies
Current Medications
Allergies
Surgeries/Hospitalizations
Past Injuries
Family Medical History
Is there a family history of (check all that apply):
Diabetes
Heart Disease
High Blood Pressure
Sudden Cardiac Death
Other Information
Any other health concerns or relevant information:
Parent/Guardian Signature
Date