Plymouth Family Physicians

Participation Physical Evaluation
(Medical History to be Retained by Physician/Provider)

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

PARENTS NEED TO BRING IMMUNIZATION RECORDS WITH THEM TO THIS VISIT AND NEED TO BE WITH CHILDREN FOR THE WIAA PHYSICALS AS THEY MAY NEED TO GIVE CONSENT FOR A TETANUS BOOSTER!

Date of Exam

Name (required)

E-mail Address

Date of Birth

Grade

Age

Sex

School

Sport(s)

City

State

Zip Code

Phone

( ) -

Personal Physician

Dr. Mary Arenberg
Dr. George Schroeder

Explain "Yes" answer(s) below. Leave blank the questions you don't know the answers to.

Yes No

Have you had a medical illness or injury since your last checkup or sports physical?

Yes No

Do you have an ongoing or chronic illness?

Yes No

Have you ever been hospitalized overnight?

Yes No

Have you ever had surgery?

Yes No

Are you currently taking any prescription or nonprescription (over-the counter) medications or pills or using an inhaler?

Yes No

Have you ever taken any supplements or vitamins to help you gain or lose weight or improve your performance?

Yes No

Do you have any allergies (for example, to pollen, medicine, food or stinging insects)?

Yes No

Have you ever had a rash or hives develop during or after exercise?

Yes No

Have you ever passed out during or after exercise?

Yes No

Have you ever been dizzy during or after exercise?

Yes No

Have you ever had chest pain during or after exercise?

Yes No

Do you get tired more quickly than your friends do during exercise?

Yes No

Have you ever had racing of your heart or skipped heartbeats?

Yes No

Have you had high blood pressure or high cholesterol?

Yes No

Have you ever been told you have a heart murmur?

Yes No

Has any family member or relative died of heart problems or of sudden death before age 50?

Yes No

Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month?

Yes No

Has a physician ever denied or restricted your participation in sports for any heart problems?

Yes No

Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus or blisters)?

Yes No

Have you ever had a head injury or concussion?

Yes No

Have you ever been knocked out, become unconscious, or lost your memory?

Yes No

Have you ever had a seizure?

Yes No

Do you have frequent or severe headaches?

Yes No

Have you ever had numbness or tingling in your arms, hands, legs or feet?

Yes No

Have you ever had a stinger, burner or pinched nerve?

Yes No

Have you ever become ill from exercising in the heat?

Yes No

Do you cough, wheeze, or have trouble breathing during or after activity?

Yes No

Do you have asthma?

Yes No

Do you have seasonal allergies that require medical treatment?

Yes No

Do you use any special protective or corrective equipment or devices that aren’t usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)?

Yes No

Have you had any problems with your eyes or vision?

Yes No

Do you wear glasses, contacts or protective eyewear?

Yes No

Have you ever had a sprain, strain or swelling after injury?

Yes No

Have you broken or fractured any bones or dislocated any joints?

Yes No

Have you had any other problems with pain or swelling in muscles, tendons, bones or joints? If yes, check appropriate area and explain below.

	Head		Neck
	Wrist		Hand
	Ankle		Forearm
	Elbow		Shin/Calf
	Knee		Thigh
	Upper arm		Shoulder
	Hip		Back
	Chest		Finger
	Foot

Explain pain or swelling indicated above:

Yes No

Do you want to weigh more or less than you do now?

Yes No

Do you lose weight regularly to meet weight requirements for your sport?

Yes No

Do you feel stressed out?

Record the dates of your most recent immunizations (shots) for:

Tetanus
Measles
Hepatitis B
Chicken Pox

Explain “Yes” answer(s) to any question above here.

FEMALES ONLY

When was your first menstrual period?

When was your most recent menstrual period?

How many days do you usually have from the start of one period to the start of another?

How many periods have you had in the last year?

What was the longest time (in days) between periods in the last year?

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.

Participation Physical Evaluation (Medical History to be Retained by Physician/Provider)

Participation Physical Evaluation
(Medical History to be Retained by Physician/Provider)