ࡱ> surq`  JbjbjqPqP *V::%>>>>>>>R:::8r4R06""DDD#!m%///////$Z1h3z0E>5'#5'5'0>>DD^0...5'p>D>D/.5'/..:O/,>>/D* b:'{/ /,t000/ <4(<4/<4>/85'5'.5'5'5'5'5'00C.X5'5'5'05'5'5'5'RRRdRRRRRR>>>>>> Austin Foundation Youth & Fitness Pre-Participation Physical Evaluation HISTORY Date:  FORMTEXT       Name: FORMTEXT       Sex:  FORMTEXT       Age:  FORMTEXT       Date of Birth:  FORMTEXT       Grade: FORMTEXT       School: FORMTEXT       Sports:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       Personal Physician:  FORMTEXT       In case of emergency, contact: Name: FORMTEXT       Relationship:  FORMTEXT       Phone (H):  FORMTEXT       (W):  FORMTEXT       ______________________________________________________________________________________ Circle questions you don't know the answers to. Explain "Yes" answers below: Yes No Have you had a medical illness or injury since your last checkup or sports physical?  FORMCHECKBOX   FORMCHECKBOX  Have you ever been hospitalized overnight?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had surgery?  FORMCHECKBOX   FORMCHECKBOX  Are you currently taking any prescription or nonprescription (over-the-counter) Medications or pills or using an inhaler?  FORMCHECKBOX   FORMCHECKBOX  Have you ever taken any supplements or vitamins to help you again or lose weight Or improve your performance in sports or athletics?  FORMCHECKBOX   FORMCHECKBOX  Do you have any allergies (for example, to pollen, medicine, food or stinging insects)?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had a rash or hives develop during or after exercise?  FORMCHECKBOX   FORMCHECKBOX  Have you ever passed out during or after exercise?  FORMCHECKBOX   FORMCHECKBOX  Have you ever been dizzy during or after exercise?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had chest pain during or after exercise?  FORMCHECKBOX   FORMCHECKBOX  Do you get tired more quickly than your friends do during exercise?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had racing of your heart or skipped heartbeats?  FORMCHECKBOX   FORMCHECKBOX  Have you had high blood pressure or high cholesterol?  FORMCHECKBOX   FORMCHECKBOX  Have you ever been told you have a heart murmur?  FORMCHECKBOX   FORMCHECKBOX  Has any family member or relative died of heart problems or of a sudden death before age 50?  FORMCHECKBOX   FORMCHECKBOX  Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the past month?  FORMCHECKBOX   FORMCHECKBOX  Has a physician ever denied or restricted your participation in sports for any heart problems?  FORMCHECKBOX   FORMCHECKBOX  Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus or blisters)?  FORMCHECKBOX   FORMCHECKBOX  Have you ever has a head injury or concussion?  FORMCHECKBOX   FORMCHECKBOX  Have you ever been knocked out, become unconscious or lost your memory?  FORMCHECKBOX   FORMCHECKBOX  Have you ever has a seizure?  FORMCHECKBOX   FORMCHECKBOX  Do you have frequent or severe headaches?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had numbness or tingling in your arms, hands, legs, or feet?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had a stinger, burner, or pinched nerve?  FORMCHECKBOX   FORMCHECKBOX  Have you ever become ill from exercising in the heat?  FORMCHECKBOX   FORMCHECKBOX  Do you cough, wheeze, or have trouble breathing during or after activity?  FORMCHECKBOX   FORMCHECKBOX  Yes No Do you have asthma?  FORMCHECKBOX   FORMCHECKBOX  Do you have seasonal allergies (for example, grass or tree pollen) that require medical attention?  FORMCHECKBOX   FORMCHECKBOX  Do you use an 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 or hearing aid)?  FORMCHECKBOX   FORMCHECKBOX  Have you had any problems with your eyes or vision?  FORMCHECKBOX   FORMCHECKBOX  Have you ever had a sprain, strain, or swelling after injury?  FORMCHECKBOX   FORMCHECKBOX  Have you broken or fractured any bones or dislocated any joints?  FORMCHECKBOX   FORMCHECKBOX  Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints? If so, please check the location(s) below: Head  FORMCHECKBOX  Elbow  FORMCHECKBOX  Thigh  FORMCHECKBOX  Neck  FORMCHECKBOX  Forearm FORMCHECKBOX  Knee  FORMCHECKBOX  Back  FORMCHECKBOX  Wrist  FORMCHECKBOX  Shin/calf FORMCHECKBOX  Chest FORMCHECKBOX  Hand  FORMCHECKBOX  Ankle  FORMCHECKBOX  Shoulder  FORMCHECKBOX  Finger  FORMCHECKBOX  Foot  FORMCHECKBOX  Upper arm  FORMCHECKBOX  Hip  FORMCHECKBOX  If yes, check appropriate box and explain below. Do you want to weigh more or less than you do now?  FORMCHECKBOX   FORMCHECKBOX  Do you chose weight regularly to meet weight requirements for your sport?  FORMCHECKBOX   FORMCHECKBOX  Do you feel stressed out?  FORMCHECKBOX   FORMCHECKBOX Record the dates of your most recent immunizations (shots): Tetanus:  FORMTEXT "D     $ ( * > @ B L N P V Z \ p ˸ע瞑ygccSgccjh^hz>*UhMU#jh^hMU>*UmHnHujth^hz>*Uh^hMU>*jh^hMU>*Uh4*jh^hMU5>*CJUmHnHu%jh^hz5>*CJUh^hMU5>*CJjh^hMU5>*CJU h45CJ hMU5CJhMUhMU5CJ n < > | p  iQPh^hh^hgdMU & FxxgdMU$a$ &dPgdMUIJp r t ~  " $ . 0 6 B F H \ ^ ` j l | qjh^hz>*Uj,h^hz>*Ujh^hz>*UjDh^hz>*Ujh^hz>*Uh^hMU>*h4hMU#jh^hMU>*UmHnHujh^hMU>*Uj\h^hz>*U,    * , . 8 : > z   " $ & 0 2 аةЙЉyjh^hz>*Ujvh^hz>*Ujh^hz>*U h456jh^hz>*Ujh^hz>*Uh^hMU>*h4hMUjh^hMU>*U#jh^hMU>*UmHnHu/2 > D H J ^ ` b l n p EFTUVWXfgh}rj hzUjhzUj4hzUjhzUjLhzUjhzUjhMUU h45#jh^hMU>*UmHnHujbh^hz>*Uh^hMU>*jh^hMU>*Uh4hMU,,-;<=>?MNO*+,-.<=>uvj hzUj: hzUj hzUjN hzUj hzUjb hzUj hzUjx hzUj hzUhMUh4jhMUUj hzU2P?Q{![Cy ch6h^hgdMUh^hh`hgdMU & F-.<=>?@NOP     WXfghijxyzjLhzUjhzUj`hzUjhzUjthzUjhmWUjhzUjhzUjhzUh4j&hzUhMUjhMUU2z78FGHIJXYZUVdefghvwxy   jhzUjrhzUjhzUjhzUjhzUjhzUj$hzUjhzUj8hzUjhzUhMUjhMUUh43 ?@NOPQR`abDESTUVWefgjhzUjhzUjhzUj"hzUjhzUj6hzUjhzUjJhzUjhzUj^hzUhMUjhMUUh43!"#$%345op~()789:;IJKj hzUjhzUj4hzUjhzUjHhzUjhzUj\hzUjhzUjphzUh4jhzUhMUjhMUU2   L+9W)xWXh^hgdMUh^hh`h & F ^ gdMU & FgdMU$%&'(678yzjF$hzUh^jh^Uj#hzUjZ#hzUj"hzUjn"hzUj!hzUj!hzUj !hzUj hzUhMUjhMUUh42   &'(-./=>?FKLZ[\fguvw}~jl(hzUj'hzUj'hzUj 'hzUj&hzUj&hzUj%hzUj2%hzUh^h4jh^Uj$hzU3  '()789=EFTUVX蕑蕑j,hzUhMUjhMUU h45j+hzUj0+hzUj*hzUjD*hzUj)hzUjX)hzUh^h4jh^Uj(hzU1XSJDDDDDTEE,FFRGGGGGGGHH0I$)&`#$/Ifgd4gd^gd^ & Fh^h/0>?@ABPQRSst D D DD"D$D8D:D*U#jh^h^>*UmHnHuUj.h^hz>*Uh^h^>*jh^h^>*Ujj.hzUj-hzUj~-hzUj-hzUh^jh^Uh4jhMUUj,hzU(      Measles:  FORMTEXT       Hepatitis B:  FORMTEXT       Chickenpox:  FORMTEXT       FEMALES ONLY When was first menstrual period? FORMTEXT       How much time do you usually have from the start of one period to the start of another? FORMTEXT       How many periods have you had in the past year? FORMTEXT       What was the longest time between periods in the past year? FORMTEXT       EXPLAIN  YES ANSWERS HERE:  FORMTEXT       I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. 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