Victory Christian Academy Athletics

Student's Name: *

Student's Adress: *

Student's Phone *

Local Persons Who Will Care For Child In An Emergency

Emergency Contact Name: *

Emergency Contact Address: *

Emergency Contact Home Phone: *

Emergency Contact Business Phone: *

Local Doctor Phone Number: *

Insurance: *

ID # *

Date: *

Last Tetanus Shot: *

Medical Information/Examination

Part 1: Family History

Student's Name: *

Father's Name: *

Mother's Name: *

Family Doctor: *

Emergency Contact: *

Relationship: *

Sex: *

Date Of Birth: *

Work Phone: *

Cell Phone: *

Part 2: Brief Medical History

He had injuries requiring medical attention *

Has had an illness requiring hospitalization

*

Is under physician's care at this time

*

Is under physician's care at this time *

Has had coughing, wheezing or trouble breathing during or after the activity

*

Has had asthma *

Has had seasonal allergies that require medical treatment

*

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

*

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

*

Have you ever passed out during or after exercise?

*

Have you ever been dizzy during or after exercise?

*

Have you ever had chest pain during or after exercise?

*

Do you get tired quicker than your friends do during exercise?

*

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

*

Have you been told that you have a heart murmur?

*

Has any family member or relative died of heart problems or of sudden death before age 55?

*

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

*

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

*

Have you ever had a head injury or concussion?

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

*

Part 3 Physical Examination

This section to be completed by a physician or nurse practitioner

Review Of Medical History

Patient Past Medical Disorder: *

Current Medical Disorders: *

List All Medications (both routine and prescription drugs) *

Physical Exam

BP *

Height *

Weight *

Vision *

Neurological *

Head/Neck *

Chest/Airway *

Skin *

Cardiovascular *

Abdomen *

Genitilia/Hernias *

Musculoeskeletal *

Strength *

Descprition Of Abnormalities Above: *

Recommendations:

There are no restrictions or special considerations to participation in the school athletic program. To include Varsity Football and All Varsity Sports. *

The following are limitations or special considerations: *

This student should be restricted from participating in high level contact sports at this time. *

This student is disqualified from sports until further evaluation. *

Physician or Nurse Practitioner Statement/Signature:

I, the undersigned, am licensed to elicit and interpret the medical history, pharmaceutical history, and clinical findings of a complete health assessment for participation in an athletic program or physical education program. I have completed this assessment and recorded all pertinent findings above.

E-Signature Physician, DO or Nurse Practitioner Signature

*

E-Signature Printed Name

*

Date Of Exam *

License Number *

Address *

City, State, Zip

*

E-Signature *

Victory Christian Academy Athletic Department Student Medical Form

Local Persons Who Will Care For Child In An Emergency

Medical Information/Examination

Part 1: Family History

Part 2: Brief Medical History

Part 3 Physical Examination

This section to be completed by a physician or nurse practitioner

Physical Exam

Recommendations:

Physician or Nurse Practitioner Statement/Signature:

Victory Christian Academy Athletic Department Student Medical Form

Victory Christian Academy Athletic Department Student Medical Form

Local Persons Who Will Care For Child In An Emergency

Medical Information/Examination Part 1: Family History

Part 2: Brief Medical History

Part 3 Physical Examination

This section to be completed by a physician or nurse practitioner

Physical Exam

Recommendations:

Physician or Nurse Practitioner Statement/Signature:

Victory Christian Academy Athletic Department Student Medical Form

Medical Information/Examination

Part 1: Family History