I am full book

Athlete Medical FormPage 1 of 3NEW RENEWAL UPDATEArea Delegation Code Delegation NameIndividual Physical MedFest® Unified Partner (medicals optional) Healthy Young AthletesATHLETE INFORMATION First NameLast NameMiddle Name NicknameDate of Birth (MM/DD/YYYY)Address Gender Male Female Eye ColorHome Phone NoEmail City/State/ZipEmployerSports the athlete is interested in playing: Cell PhoneEmergency Contact (if different from Parent/Guardian below)Cell Phone I am my own guardian. Yes Employer’s City/State Relationship to AthletePARENT/GUARDIAN INFORMATION First NameRelationship to Athlete Cell PhoneLast Name City/State/ZipHome PhoneAddress Employer’s City/StateEmailEmployerATHLETE MEDICAL INFORMATION Physician’s PhonePrimary Care PhysicianPhysician’s Address City/State/ZipHealth Insurance ProviderThe athlete has (check all that apply) Autism Down Syndrome Fragile X Syndrome Cerebral Palsy Fetal Alcohol Syndrome Other syndrome (please specify):The athlete uses (check any that apply) Wheelchair Brace Removable Prosthetics Crutches or Walker Splint Dentures Communication Device Pacemaker G-Tube or J-Tube Implanted Device Inhaler Colostomy C-PAP Machine Glasses or Contacts Hearing AidAthlete’s Allergies (please list) No Known Allergies Latex Insect Bites or Stings: Food: Medications:Special Dietary NeedsDoes the athlete have any religious objections to medical treatment? No Yes If yes, please complete the religious objections form.Does the athlete currently have any chronic or acute infection? No Yes If yes, please describe:





Food For Fitness



Athlete Medical FormPage 1 of 3NEW RENEWAL UPDATEArea Delegation Code Delegation NameIndividual Physical MedFest® Unified Partner (medicals optional) Healthy Young AthletesATHLETE INFORMATION First NameLast NameMiddle Name NicknameDate of Birth (MM/DD/YYYY)Address Gender Male Female Eye ColorHome Phone NoEmail City/State/ZipEmployerSports the athlete is interested in playing: Cell PhoneEmergency Contact (if different from Parent/Guardian below)Cell Phone I am my own guardian. Yes Employer’s City/State Relationship to AthletePARENT/GUARDIAN INFORMATION First NameRelationship to Athlete Cell PhoneLast Name City/State/ZipHome PhoneAddress Employer’s City/StateEmailEmployerATHLETE MEDICAL INFORMATION Physician’s PhonePrimary Care PhysicianPhysician’s Address City/State/ZipHealth Insurance ProviderThe athlete has (check all that apply) Autism Down Syndrome Fragile X Syndrome Cerebral Palsy Fetal Alcohol Syndrome Other syndrome (please specify):The athlete uses (check any that apply) Wheelchair Brace Removable Prosthetics Crutches or Walker Splint Dentures Communication Device Pacemaker G-Tube or J-Tube Implanted Device Inhaler Colostomy C-PAP Machine Glasses or Contacts Hearing AidAthlete’s Allergies (please list) No Known Allergies Latex Insect Bites or Stings: Food: Medications:Special Dietary NeedsDoes the athlete have any religious objections to medical treatment? No Yes If yes, please complete the religious objections form.Does the athlete currently have any chronic or acute infection? No Yes If yes, please describe:







Athlete Medical FormPage 2 of 3Athlete Last Name Athlete First NameATHLETE MEDICAL HISTORYList all past surgeries:List all ongoing or past medical conditions:List all medical conditions that run in the athlete’s family:Has any relative died of a heart problem before age 40? No Yes Has any relative died while exercising? No YesHas a doctor ever limited the athlete’s participation in sports? No Yes If yes, please describe:Has the athlete ever had an abnormal Electrocardiogram (EKG)? No Yes If yes, please describe:Has the athlete ever had an abnormal Echocardiogram (Echo)? No Yes If yes, please describe:Has the athlete had a Tetanus vaccine within the past 7 years? No YesPLEASE INDICATE IF THE ATHLETE HAS EVER HAD ANY OF THE FOLLOWING CONDITIONSLoss of Consciousness No Yes High Cholesterol No Yes Asthma No Yes Vision Impairment No YesDizziness during or after exercise No Yes Hearing Impairment No Yes Diabetes No Yes Enlarged Spleen No YesHeadache during or after exercise No Yes Single Kidney No Yes Hepatitis No Yes Osteoporosis No YesChest pain during or after exercise No Yes Osteopenia No Yes Urinary Discomfort No Yes Sickle Cell Disease No YesShortness of breath during or after exercise No Yes Sickle Cell Trait No Yes Spina Bifida No Yes Easy Bleeding No YesIrregular, racing or skipped heat beats No Yes Dislocated Joints No Yes Arthritis No Yes Stroke/TIA No YesCongenital Heart Defect No Yes Concussions No Yes Heat Illness No YesHeart Attack No Yes Broken Bones No YesCardiomyopathy No Yes Please describe any broken bones orHeart Valve Disease No Yes dislocated joints:Heart Murmur No YesEndocarditis No YesHigh Blood Pressure No YesAny difficulty controlling bowels or bladder No Yes If yes, is this new or worse in the past 3 years? No Yes No YesNumbness or tingling in legs, arms, hands or feet No Yes If yes, is this new or worse in the past 3 years? No YesWeakness in legs, arms, hands or feet No Yes If yes, is this new or worse in the past 3 years? No YesBurner, stinger, pinched nerve or pain in the neck, No Yes If yes, is this new or worse in the past 3 years? No Yesback, shoulders, arms, hands, buttocks, legs or feet No Yes No YesHead Tilt No Yes If yes, is this new or worse in the past 3 years? No YesSpasticity No Yes If yes, is this new or worse in the past 3 years? No Yes No YesParalysis No Yes If yes, is this new or worse in the past 3 years?Epilepsy or any type of seizure disorder No Yes If yes, list seizure type: Seizure during the past year?Self-injurious behavior during the past year No Yes Aggressive behavior during the past yearDepression No Yes AnxietyPlease describe any additional mental health concerns:

Further Medical Evaluation FormONLY TO BE USED IF THE ATHLETE HAS PREVIOUSLY NOT BEENCLEARED FOR SPORTS PARTICIPATION ON THE PREVIOUS PAGEAthlete Last Name Athlete First NameFURTHER MEDICAL EVALUATION SpecialtyExaminer’s NameI have examined this athlete for the following medical concern(s): Please describe. YES NO In my professional opinion, this athlete may participate in Special Olympics sports (see below for restrictions or limitations).Additional Licensed Examiner Notes:Signature DatePrinted Name EmailPhone LicenseFURTHER MEDICAL EVALUATION SpecialtyExaminer’s NameI have examined this athlete for the following medical concern(s): Please describe. YES NO In my professional opinion, this athlete may participate in Special Olympics sports (see below for restrictions or limitations).Additional Licensed Examiner Notes:Signature DatePrinted Name EmailPhone LicenseFURTHER MEDICAL EVALUATION SpecialtyExaminer’s NameI have examined this athlete for the following medical concern(s): Please describe. YES NO In my professional opinion, this athlete may participate in Special Olympics sports (see below for restrictions or limitations).Additional Licensed Examiner Notes:Signature DatePrinted NamePhone Email License



Interactive content is a better way to educate, entertain, and engage audience I AM Smart Living Manual