Ohio Christian University Physical Examination Form

Name:______

SSN:______Student ID Number______

Date of Birth:______/______/______Cell Phone Number:______

Ohio Christian University Annual Athletic Pre-Participation Physical Examination Form

DATE OF EXAM:______
Name ______Sex ______Age ______
Date of Birth ______/______/______
Grade______School ______
Sport(s)______
Home Address: ______City______State______Zip______
Cell Phone Number:______
PersonalPhysician______
In case of emergency, contact: Name ______Relationship ______
Phone (H) ______(W)______(Cell)______(Cell)______

History: This section is to be carefully completed by the student athlete/ parent/legal guardian before participation in intercollegiate athletics in order to help detect possible risks.

  1. Has a doctor ever denied or restricted your participation in sports for any reason? Yes No
  2. Do you have an ongoing medical condition (like diabetes or asthma)? YesNo
  3. Are you currently taking any prescription or non-prescription drugs or pills? YesNo
  4. Do you have allergies to medicines, foods, pollen, or stinging insects? Yes No
  5. Do you think you are in good health? Yes No
  6. Have you ever passed out or nearly passed out DURING exercise? YesNo
  7. Have you ever passed out or nearly passed out AFTER exercise? YesNo
  8. Does your heart race or skip beats during exercise?YesNo
  9. Has your doctor ever told you that you have (circle those that apply): *high blood pressure *high cholesterol *heart murmur * heart infection
  10. Has a doctor ever ordered a test for your heart? (ECG, echocardiogram)YesNo
  11. Have you ever had pain, discomfort or pressure in your chest during exercise? YesNo
  12. Has anyone in your family died for no apparent reason?YesNo
  13. Does anyone in your family have a heart problem? YesNo
  14. Has any family member or relative died of heart problems or sudden death before the age of 50? Yes No
  15. Does anyone in your family have MarfanSysndrome? YesNo
  16. Have you ever spent the night in the hospital? YesNo
  17. Have you ever had surgery?YesNo
  18. Have you ever had an injury, like a sprain, muscle or ligament tear, or tendonitis that caused you to miss a practice or game? If yes, please write in what and when:______
  1. Have you ever had any fractured, broken or dislocated bones/ joints? If yes, please write in what and when: ______
  2. Have you ever had a bone or joint injury that required X-rays, MRI, CT, surgery, injections, rehabilitation, a brace, cast or crutches? If yes, please explain: ______
  3. Have you ever had a stress fracture? YesNo
  4. Has anyone ever told you that you have or have you had a X-ray for atlantoaxial (neck) instability?YesNo
  5. Do you regularly use a brace or assistive device? YesNo
  6. Has a doctor ever told you that you have asthma or allergies? YesNo
  7. Do you cough, wheeze, or have difficulty breathing during or after exercise? YesNo
  8. Does anyone in your family have asthma? YesNo
  9. Have you ever used an inhaler or used asthma medicine? YesNo
  10. Were you born without or are you missing an eye, testicle, kidney or any other organ? Yes No
  11. Have you had infectious mononucleosis (mono) within the last month?YesNo
  12. Do you have any rashes pressure sores or other skin problems? YesNo
  13. Have you had a herpes skin infection? YesNo
  14. Have you ever had a head injury or concussion? YesNo
  15. Have you been hit in the head and been confused or lost you memory? Yes No
  16. Have you ever had a seizure?YesNo
  17. Do you have headaches with exercise?YesNo
  18. Have you ever had tingling, numbness, or weakness in your arms after being hit or falling? YesNo
  19. Have you ever been unable to move your arms or legs after being hit or falling? YesNo
  20. When exercising in the heat, do you have severe muscle cramps or become ill? YesNo
  21. Has a doctor told you that you or someone in your family has Sickle Cell trait or disease? Yes No
  22. Do you have problems with your eyes or vision?YesNo
  23. Do you wear glasses or contact lenses?YesNo
  24. Do you wear protective eyewear like goggles or a face shield? YesNo
  25. Are you happy with your weight?YesNo
  26. Are you trying to gain or lose weight?YesNo
  27. Has anyone recommended that you change your weight or eating habits?YesNo
  28. Do you limit or carefully control what you eat? YesNo
  29. Do you have any concerns that you would like to discuss with a doctor? YesNo
  30. Please Explain All “Yes” Answers:

______

Females Only

  1. Have you ever had a menstrual period?YesNo
  2. How old were you when you had your first menstrual period? ______
  3. How many periods have you had in the last 12 months? ______

I hereby state, to the best of my knowledge, my answers above are correct and complete.

Signature:______

Guardian Signature (under 18): ______

Date:______/______/______

Physical Examination Form

These sections to be filled out by physician or staff member after history and consent forms are completed.

Athlete Name:______Birth date: ______

Height: ______Weight: ______Body Fat % (optional)______

Pulse: ______Blood Pressure:______/______,______/______,______/______

Vision: R 20/____, L 20/____Corrected? Yes NoPupils: EqualUnequal

Medical / Normal / Abnormal Findings / Initials
Appearance
Ears/nose/throat
Hearing
Lymph Nodes
Heart
Murmurs
Pulse
Lungs
Abdomen
Genitalia (males)
Skin
Musculoskeletal
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/hand/fingers
Hip/ thigh
Knee
Leg/ ankle
Feet/toes

Notes: ______

Clearance:

Cleared without restriction______

Cleared, with recommendations for treatment of: ______

Not Cleared for: All SportsCertain sports:______

Reason:______