Name __________________________________ Age ____ Exam Date ___________

Social Security Number: ________________ Birth Date: ________

Home Address: _________________________________________________________

Home Telephone Number: ________________

Medical History

YES NO

		Chronic or recurrent illnesses? (diabetes, asthma, ulcers, etc)
		Hospitalizations?
		Illness lasting more than a week?
		Surgery other than tonsillectomy? (tonsils removed)
		Surgery advised and not done?
		Presently taking any medications? (if so list)
		Problem with blood pressure or heart?
		Seizures, dizziness, fainting, convulsions or frequent headaches?
		Ever been knocked out or had a concussion?
		Wear eyeglasses or contact lenses?
		Wear any dental appliance such as: braces, bridge, or plates?
		Allergic to ANY medication (aspirin, penicillin, etc.)? (if so list)
		Allergic to ANY foods (shrimp, poppy seeds, tomatoes, etc.)? (if so list)
		Organ missing other than tonsils (appendix, eye, kidney, testicle)?
		Heat exhaustion or heat stroke?
		History of enlarged liver or spleen?
		History of collapsed lung or tuberculosis?
		Serious eye injuries?
		Has any family member died suddenly at less than age of 40 of illness (not an accident)?
		Has any family member had a heart attack before age 55?
		History of knee injury?
		History of ankle injury?
		History of neck injury?
		History of other joint sprains or dislocations (shoulder, wrist, finger, etc)?
		History of broken bones (fractures)?
		Date of last known tetanus (lockjaw) shot. ______________

Weight _______ Pulse Rate ____b/min Height _______ Blood Pressure _________

Vision R ______ L ______ Both ______ Corrective Lense __Y/____N

Musculo-Skeletal Assessment

Grade of 1,2,3

1 = poor, 2 = average, 3 = good

General Physical Examination

Physicians Signature ____________________________________ Date _____________