Central Carolina Community College
Physical Form
This form is to be filled out and filed with the Athletic Director before the student-athlete
can practice or participate in any intercollegiate sport(s).
Student
_____________________________________
Date _____________
Address
_____________________________________
Ph. # _____________
_____________________________________
Physician
_____________________________________
Address
_____________________________________
Ph. # _____________
_____________________________________
I hereby apply for permission to participate in the following sport(s):
________________________________________________________________________
I certify that the information in this application is correct. I give permission for the
information to be shared with Central Carolina Community College Athletic Program
Personnel to include: Athletic Director, Coaches, Athletic Trainers, and Athletic Program
Administartors.
Signature of student-athlete _________________________________ Date ___________
Medical History
(Completed by the student-athlete)
Full Name ________________________
Age ______
D.O B. _____________
Is there a known history of:
a.
b.
c.
d.
e.
f.
g.
Birth Deformities (one eye, one kidney, etc.)
Past illness of more than one week duration
Medical condition currently under treatment
Fractures or other disabling injuries
Any permanent deformity or disability
Allergies (i.e. medications, foods, etc.)
Mental disorders or convulsions
Yes
___
___
___
___
___
___
___
No
___
___
___
___
___
___
___
Explain any above questions answered, “Yes”: __________________________________
________________________________________________________________________
________________________________________________________________________
Preparticipation Cardiovascular Screening of Competitive Athletes
Personal history, if yes, please explain
1. Exertional chest pain/discomfort ___________________________________________
2. Unexplained syncope/near syncope _________________________________________
3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
________________________________________________________________________
4. Prior recognition of a heart murmur ________________________________________
5. Elevated systemic blood pressure __________________________________________
Family history, if yes, please explain
6. Premature death (sudden and unexpected, or otherwise) before age 50 yrs. due to heart
disease, in .1 relative ______________________________________________________
7. Disability from heart disease in a close relative, age 50 yrs. or younger_____________
________________________________________________________________________
8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or
dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan
syndrome, or clinically important arrhythmias __________________________________
_______________________________________________________________________
Points 9-12 to be completed by a Physician. Continued on last page.
Questions Regarding Presence of Cardiovascular Risk Factors
Have you ever passed out during or after exercise? ______________________________
Have you ever been dizzy during or after exercise? ______________________________
Have you ever had chest pain during or after exercise? ___________________________
Do you get tired more quickly than your friends do during exercise? ________________
Have you ever had racing of your heart or skipped heartbeats? _____________________
Have you ever been told you have high blood pressure or high cholesterol? ___________
Have you been told you have a heart murmur? __________________________________
Has any family member or relative died of heart problems of heart problems or of sudden
death before age 50? ______________________________________________________
Have you had a severe viral infection (for example, myocarditis or mononucleosis)
within the last month? _____________________________________________________
Has a physician ever denied or restricted your participation in sports for any heart
problem? _______________________________________________________________
Explain any answers in more detail, if necessary
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I certify that I have fully and truthfully answered the Preparticipation Screening
questions. Failure to do so may result in my termination from the CCCC Athletic
Program.
Student-Athlete Signature
Printed Name
Date
______________________________________
______________________________________
___________________
Reviewed By:
Athletic Director
Date
______________________________________
___________________
Coach(es)
Date
______________________________________
___________________
Physical examination (To be filled out by physician)
Height: _________
Weight: __________ Temp.: __________ B.P.: ____________
1. Eyes
Normal
_______
Abnormal
_______
Description of Abnormalities
______________________________
2. E.N.T.
_______
_______
______________________________
3. Lungs
_______
_______
______________________________
4. Abdomen
_______
_______
______________________________
5. Genitalia
_______
(males only)
6. Musculoskeletal _______
_______
______________________________
_______
______________________________
7. Neurological
_______
_______
______________________________
8. Skin
_______
_______
______________________________
Cardiovascular: Screening questions on pgs. 2-3
9. Heart murmur _________________________________________________________
10. Femoral pulses to exclude aortic coarctation ________________________________
11. Physical stigmata of Marfan syndrome ____________________________________
12. Brachial artery blood pressure (sitting position) _____________________________
Laboratory (where indicated)
________________________________________________________________________
________________________________________________________________________
I certify that I have examined the above named student and that such examination
revealed ( conditions / no conditions ) that would prevent this student-athlete from
participating in the intercollegiate sport(s) requested.
Physician’s signature __________________________________
Date _____________
Licensed to practice medicine in North Carolina
No ______
Yes ______
If not qualified, please list reason: (i.e. licensed in another state, etc.)
________________________________________________________________________
________________________________________________________________________