Sports Physical Intake Form
Please complete this form prior to your sports physical examination. All information is confidential and necessary for safe participation.
Athlete's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Parent/Guardian Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History (Check all that apply)
*
Asthma
Diabetes
Heart Condition
Seizure Disorder
Concussion History
None
Other
List any allergies (medication, food, environmental)
Current medications (please list all)
Do you have any current symptoms, injuries, or health concerns?
Sports to be played
*
Soccer
Basketball
Football
Baseball/Softball
Track & Field
Other
Parent/Guardian Signature
*
Submit
Submit
Should be Empty: