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    THIS SECTION IS TO BE FILLED OUT BY PARENT

    Have you had or do you now have:

    NO

    YES

    EXPLAIN

    1. Brain concussion (head injury)

     

     

     

    2. Convulsion or epilepsy

     

     

     

    3. Neck injury

     

     

     

    4. Impaired vision in either eye

     

     

     

    5. Chest pain with exertion or unexplained shortness of breath

     

     

     

    6. Hearing loss

     

     

     

    7. (Boys) Loss of function of testicle

     

     

     

    8. (Girls) Is there a problem with irregular menstrual periods?

     

     

     

    9. Bone fracture

     

     

     

    10. Joint dislocation

     

     

     

    11. Orthopedic or sports injury

     

     

     

    12. Diabetes

     

     

     

    13. Asthma

     

     

     

    14. Allergy

     

     

     

    15. Heart trouble or murmur

     

     

     

    16. High blood pressure

     

     

     

    17. Need for daily medication

     

     

     

    18. Need for emergency medication

     

     

     

    19. Congenital abnormalities

     

     

     

    20. HIV Positive 

     

     

     

    21. Surgery

     

     

     

    22. Overnight hospitalization

     

     

     

    23. Fainting or lost consciousness during exercise

     

     

     

    24. An immediate family member diagnosed with heart disease. I.E.

    an abnormal heart rate, heart attack, had an angioplasty or bypass, cardiomyopathy, Marfan Syndrome, long QT Syndrome.

     

     

     

     

    By executing this document, we acknowledge and agree that to the best of our knowledge there is nothing that we are aware of that would preclude our child’s participation in swimming/diving. We acknowledge that participation in sports can result in physical contact, exertion, injuries, and any other consequences of participation. 

     

    Parent or Guardian’s Signature _______________________________________

     

    Date ____________

     

     

     

     

     

    PAGE 1 OF 2

     

    PHYSICAL EXAMINATION RECORD

     

     

    Name______________________________ Date ________________ Age_____________ Date of Birth______________

     

    Height______________________       Vision:   R______/________, Corrected_______, Uncorrected_______

     

    Weight______________________                                  L______/________, Corrected_______, Uncorrected_______

     

    Hearing: Normal __________  Abnormal___________

     

    Pulse___________________  Blood Pressure________________  Min. Weight (Wrestling) ______________________

     

    Â鶹´«Ã½ immunizations: ______DT  _______Polio  _______ MMR

     

     

    Normal

    Abnormal Findings

    Initials

    1. Eyes

     

     

     

    2. Ears, Nose, Throat

     

     

     

    3. Mouth & Teeth

     

     

     

    4. Neck

     

     

     

    5. Cardiovascular

     

     

     

    6. Lungs

     

     

     

    7. Abdomen

     

     

     

    8. Skin

     

     

     

    9. Genitalia – Hernia (Male)

     

     

     

    10. Musculoskeletal; ROM, strength, etc.

     

     

     

    a) Neck

     

     

     

    b) Spine

     

     

     

    c) Shoulders

     

     

     

    d) Arms/hands

     

     

     

    e) Hips

     

     

     

           f)     Thighs

     

     

     

    g) Knees

     

     

     

    h) Ankles

     

     

     

           i)     Feet

     

     

     

    11.  Neuromuscular

     

     

     

    12.  Physical Maturity (Tanner stage)

    1.

      2.            3.           4.           5.

     

     Comments re: Abnormal Findings: 

     

     

     

    PHYSICAL EXAMINATION RECORD PARTICIPATION RECOMMENDATION:

     

    ______________The above named child may participate in swim clinics and/or competitive level swimming/diving.  He/she is a patient of this practice and is up to date with all immunizations and is in good health.  He/she has been seen in my office for a physical within two years of today’s date.  To the best of my knowledge there is nothing that we are aware of that would preclude this child’s participation in swimming/diving activities.  

     

    ______________The above named child should not participate in swim clinics and/or competitive level swimming/diving activities.  

     

    Physician’s Signature: ________________________ Physician’s Printed Name: _____________________ 

     

    Date: ______________ Phone Number: ____________________ 

     

    Physicians

    Stamp Required

     

    Page 2 of 2

     

     

     

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