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ÐÏà¡±á>þÿ µ¸þÿÿÿ³´ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Ácà ø¿Ãbjbj ºx÷[\x÷[\Soÿÿÿÿÿÿ·ÈÈ@@@@@4ÿÿÿÿttthÜ<<td8®TTL ã7å7å7å7å7å7å7$:¶È<b 8@ 8@@ ï8ííí²@ @ ã7íã7ííª×5|O7 ÿÿÿÿà¶S„<ÔÿÿÿÿApS6Ï7480d8e6ê*=±<*=$O7*=@O7€í 8 8íd8ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿ*=È>: USIU PHYSICAL FITNESS ASSESMENT FORM Dear Health Care Provider: This form is required for students who intend to compete on Varsity athletic teams Name of Student: ___________________________________________ DOB: ___________________ Student cell phone: ____________________ Student email (active):___________________________________ A. Medications (regular/daily use): Please list ALL regular medications, including over-the-counter medications, multivitamins, and supplements. B. Personal and Family Health History (please circle yes or no for ALL questions) CARDIAC (Personal History) Yes No Exertional chest pain/discomfort Yes No Unexplained syncope/fainting or near-syncope Yes No Excessive exertional and unexplained dyspnea/fatigue, associated with exercise Yes No Prior recognition of a heart murmur Yes No Elevated systemic blood pressure Yes No Prior restriction from participation in sports due to cardiovascular reasons Yes No Prior testing for the heart, ordered by a physician (*) CARDIAC (Family History) (*) Yes No Premature death (sudden and unexpected, or otherwise) before age 50 years, due to heart disease in one or more relatives Yes No Disability from heart disease in a close relative less than 50 years old Yes No Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan Syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members NEUROLOGICAL Yes No Concussion(s) Yes No Migraine headaches Yes No Head/neck injury Yes No History of seizures GENERAL Yes No Chronic illness(es) Yes No Exercise induced bronchospasm/asthma Yes No Joint instability/joint surgery/joint injuryYes No Eating disorder Yes No Other medical or psychological issues or concerns Yes No Heat-related illness Yes No Loss of a paired organ Yes No History of bleeding disorder Yes No Severe anemia Yes NoHistory of fractures NOTE TO PROVIDER: Questions marked with (*) and answered with a Yes in the above section will require additional documentation. Please comment on all Yes answers in Section C. Personal and Family Health History. Include dates and details of onset, predominant symptoms, time lost from sport and/or school, and whether issues persist or have resolved: C. ADHD Treatment Yes No Is the student taking prescribed medication for Attention Deficit Hyperactivity Disorder (ADHD)? D. Testing for Sickle Cell Trait Yes No Has the student been tested for Sickle Cell Trait? If yes, please submit documentation of test results with this packet E. Athletic Physical Exam (please circle all answers individually) NOTE TO PROVIDER: Any questions marked with (*) and answered with a Yes or Abnormal in this category will require additional documentation. Abnormal Normal Cranial Nerves (II-XII) Abnormal Normal Lungs Abnormal Normal Eyes/ears/hearing Abnormal Normal Abdomen Yes No Glasses or contact lenses Yes No Hernia Abnormal Normal Reflexes Abnormal Normal Skin Abnormal Normal Balance/coordination Abnormal Normal Oral cavity/teeth Abnormal Normal Hips Abnormal Normal Neck/back Abnormal Normal Genitalia/testicles (men only) Abnormal Normal Shoulders Abnormal Normal Legs/knees/feet (lower extremity) Abnormal Normal Arms/wrists/hands (upper extremity) Yes No Does the student have a heart murmur? (*) Yes No Does the student have a cardiac arrhythmia? (*) Yes No Does the student have food or drug allergies? (*) Abnormal Normal Bilateral femoral pulses to exclude aortic coarctation Abnormal Normal Cardiovascular exam F. Vital Signs Height (in): _________ Brachial artery blood pressure in sitting (Must complete both arms): Weight (lbs): ________ Left arm (mmHg): _______ / _______ Resting Pulse (bpm): _________ Right arm (mmHg): _______ / _______ G. Laboratory/Radiology Investigations Have the following tests being done? If yes please attach report. FORM FOR TESTS REQUESTSRESULTSECGExercise Stress Testing Full HGM Urinalysis Lipid ProfileToxicology ScreenPickling Trait Test H. MEDICAL CLEARANCE Yes No Are additional test results or cardiology consults pending? If so, which? _____________________ Yes No In your opinion is this student medically able to participate in sports? 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