EAST TULSA YOUTH SPORTS ASSOCIATION
PRE-PARTICIPATION HISTORY & PHYSICAL EVALUATION

Name of Student____________________________________________
Date Of Birth ___-____-_______  Age_____ Gender_____ Race___________
HISTORY TO BE COMPLETED BY A PARENT OR GUARDIAN
1. Have any members of your family under 50 had a "heart attack" or "heart problem"?________
2. Have you ever been told you have a heart murmur, high blood pressure, extra heart beats, or a heart abnormality?________
3. Do you have to stop while running around a 1/4 mile track twice?_______
4. Are you taking any medications?_______
5. Have you ever "passed out" or been "knocked out" (concussion)?_______
6. Have you ever had any illness, condition, or injury that:
    a. Required you to go to the hospital either as a patient overnight or in the emergency room for x-rays?_______
    b. Required an operation______
    c. Lasted longer than a week?_______
    d. Caused you to miss a game r practice?_______
    e. Is related to allergies (hay fever, hives, asthma, or medication)?_______
The information I have provided is correct to the best of my knowledge and I _______________________ (name of parent/guardian) hereby give permission for___________________________(name of student) to have a medical examination, as arranged by the program, before he or she starts sport participation.
Name of sport_______________________________
I am the legal parent or guardian of this student.

Sign___________________________________  Date___-___-______
........................................................................................................................................
PHYSICAL
To be filled in and signed by the examining physician
Date___-___-_______ l        normal                             l   Abnormal findings            
Eyes , Ears, Nose        l                                             l                                      l
Throat                      l                                              l                                     l
Neck                         l                                             l                                      l
Cardiovascular            l                                              l                                     l
Chest and Lungs         l                                              l                                     l
Abdomen                   l                                              l                                     l
Skin                          l                                              l                                     l
Musculoskeletal:       l                                              l                                     l
ROM, Strength, etc      l                                             l                                      l
a. neck                      l                                             l                                      l
b. spine                     l                                              l                                     l
c. shoulders                l                                             l                                      l
d. arms/hands             l                                              l                                     l
e. hip/thigh                 l                                              l                                     l
f. knees                     l                                              l                                      l
g. ankles/feet              l                                              l                                     l
HEIGHT                         WEIGHT                           PULSE                                                      
BLOOD PRESSURE                                                                                                                  
CLEARANCE
_____CLEARED
_____LIMITED PARTICIPATION:___________________________________
_____NOT CLEARED FOR:______________________________________________
REASON:______________________
DATE:_____-_____-_______SIGNED_____________________________________________