Boxing Physical Examination
Complete this form for a comprehensive pre-fight medical assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever had any of the following? (Check all that apply)
*
Concussion or head injury
Loss of consciousness
Seizures
Heart problems
Asthma or breathing problems
Fainting spells
None of the above
List all current medications and allergies
Do you have any current symptoms (e.g., headache, dizziness, chest pain, shortness of breath)?
Boxing Experience (years/months, number of fights)
Physical Assessment
*
Rows
Normal
Abnormal
Vision
1
2
Hearing
3
4
Blood Pressure
5
6
Pulse
7
8
Lungs
9
10
Heart
11
12
Neurological exam
13
14
Physician's Clearance Decision
*
Cleared for boxing
Not cleared for boxing
Physician's Notes / Recommendations
Signature of Boxer (or Guardian if under 18)
*
Submit Examination
Submit Examination
Should be Empty: