Shaw University Sports Medicine
Student-Athlete
Medical History and Physical
Last Name (print
First Name
Sport: _______________________
Middle Initial
Home Address (Number & Street)
City
Date of Birth
Student ID #:__________________
State
Social Security Number
Zip
Gender
Telephone Number
Marital Status
Year of Graduation
Semester of Registration
Insurance Company
Policy Number
Have Any of Your Relatives Ever Had Any of The Following?
Name/ Relationship of Next of Kin
Yes
Address/Phone of Next of Kin
PARENTS OF STUDENTS UNDER 18: I hereby authorize any medical treatment for
my son/daughter which may be advised or recommended by the physicians of the
Student Health Service or Sports Medicine Department of Shaw University
_______________________________________________
Signature of Parent/Guardian
Date
PERSONAL HISTORY PLEASE ANSWER ALL QUESTIONS
Yes
No
Have You Had
Have You Had
Eye Trouble
Ear, Nose, Throat
Frequent or Sever
Headaches
Epilepsy
Asthma, Hay fever, Hives
Yes
Frequent or sever
Respiratory Infections
Rheumatic Fever or
Heart Mummer
Stomach or Intestinal
Trouble
No
Relationship
Tuberculosis
Diabetes
Heart Disease
Kidney Disease
Arthritis
Stomach Disease
Asthma, Hay Fever
Epilepsy, Convulsions
Comment on all positive answers in space below or on additional sheet
Yes
No
Yes
Have You Had
Have You Had
No
Kidney or Bladder
Disease
Disease or Injury of
Bones or joints
“Trick” Knee or Shoulder
Diabetes
Infect. Mononucleosis
Sickle Anemia
Females only
Hepatitis or Jaundice
Tuberculosis
Asthma
Irregular Period
Severe Cramps
Excessive Flow
Yes No
Remarks or Additional Information
(Use Extra Paper if Necessary)
A.
Do you have any disease, or is any drug or other
treatment being followed, which should be continued
or periodically evaluated? (Details)
B.
Have you any drug allergy or other known sensitivity or
intolerance? (Details)
C.
Have you had any illness, injury, or operation or been
hospitalized other than as already noted? (Details)
D.
Has your physical activity been restricted during the past five
years? (Why)
E.
Have you ever been hospitalized for mental or emotional
illness? {Give Names and address of doctors and/or hospitals}
F.
Have you ever interrupted school or work either because of
mental or emotional illness or after psychiatric consultation?
{Give Names and address of doctors and/or hospitals}
Statement by Student: I have personally supplied the above information and
attest that it is true and complete to the best of my knowledge. I hereby give my
permission to any doctor, hospital, or other medical agency to release
confidentially to the Student Health Service Physician(s) or Sports Medicine Staff
of Shaw University any information they may have concerning my medical
condition and their professional contact with me.
A photocopy of this permission is considered as valid as original.
____________________________________________________
Signature of Student
Date
___________________________________________________________________
Physician’s Signature (Acknowledging Review)
Date
No
Shaw University Sports Medicine
Student-Athlete
Medical History and Physical
Student ID #:__________________
Sport: _______________________
To the Examining Physician: Please review the student-athletes history and complete the physician’s form. Please comment on all positive
answers. The information supplied will be used as a background for providing health care. This information is strictly for Sports Medicine
and will not be released without the students consent.
Last Name
First Name
Middle Name
Height: __________ Inches
Weight: ___________lbs.
B.P. ________/________
Pulse: ___________min.
Corrected Vision:
Right:____________
Left: ____________
Hearing (gross):
Right: ____________
Left: ____________
Urinalysis
Sugar: ______________
Albumin: __________________
Micro: __________________
Hematocrit (if indicated Sickle Cell:
____________________%
Vaccine
Date
Date
Date
Date
Date
DTP
Td or Tetanus Booster
Polio, oral
Rubeola (measles, MMR)
Disease Date
Disease Date
Mumps (MMR)
Rubella (German measles, MMR)
Are there any abnormalities?
Yes
No
Head, Ears, Nose, Throat
Eyes
Respiratory
Cardiovascular
Gastrointestinal
Hernia
Genitourinary
Musculoskeletal
Shoulders
Hips
Knees
Ankles
Feet
Metabolic/Endocrine
Neuropsychiatric
Skin
Mammary
A.
B.
C.
D.
E.
Is there loss or seriously impaired function of any paired organ? _____________________________________
Have you any general comments? ______________________________________________________________
Recommendation for physical activity (sports)? Unlimited ________________ Limited ___________________
Do you have any recommendations regarding the care of this Student Athlete? Yes ________ No __________
Is the student now under treatment for any medical or emotional condition? Yes _________No ___________
____________________________________________
Signature of physician/pa/np
Date