| Medical
Release Form 2005-2006
STUDENT
NAME ______________________________________________
Student
date of birth: ___________________________________________
Date
of Examination ___________________________________________
Participation
evaluation -- History
- Have
any members of your family under age 50 had a "heart attack"
or "heart problems"? Yes _____ No _____
- Have
you ever been told you have a heart murmur, high blood pressure,
or a heart abnormality? Yes ____ No ____
- Do
you have to stop while running a short distance (1/4 mile) due
to shortness of breath? Yes ____ No ____
- Are
you taking any medications? Yes ____ No ____
- Have
you ever "passed out" or had a concussion? Yes ____
No ____
- Have
you ever had any illness, condition or injury that:
- Required
hospital care? Yes ____ No ____
Please
explain if you answered "yes" to any of the above. _____________________
_________________________________________________________________
The
following must be completed by PHYSICIAN
---------------------------------------------------------------------------------------------------------------------
Physician's
Name ___________________________________________________
Telephone / Address ________________________________________________
Disposition:
- The
student may NOT participate in: _________________________________
_____________________________________________________________
- Limited
participation in: __________________________________________
- Requires
: _____________________________________________________
- Full
participation is granted: _______________________________________
Signed
___________________________________
Date _____________________________________ |
