Medical Release Form 2005-2006

STUDENT NAME ______________________________________________
Student date of birth: ___________________________________________
Date of Examination ___________________________________________

Participation evaluation -- History

1. Have any members of your family under age 50 had a "heart attack" or "heart problems"? Yes _____ No _____
2. Have you ever been told you have a heart murmur, high blood pressure, or a heart abnormality? Yes ____ No ____
3. Do you have to stop while running a short distance (1/4 mile) due to shortness of breath? Yes ____ No ____
4. Are you taking any medications? Yes ____ No ____
5. Have you ever "passed out" or had a concussion? Yes ____ No ____
6. Have you ever had any illness, condition or injury that:
   • Required hospital care? Yes ____ No ____

Please explain if you answered "yes" to any of the above. _____________________
_________________________________________________________________

The following must be completed by PHYSICIAN
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Physician's Name ___________________________________________________
Telephone / Address ________________________________________________

Disposition:

1. The student may NOT participate in: _________________________________
   _____________________________________________________________
2. Limited participation in: __________________________________________
3. Requires : _____________________________________________________
4. Full participation is granted: _______________________________________

Signed ___________________________________
Date _____________________________________