This document is a sports evaluation form for Bloomsburg Midget Football. It collects health history information from a parent or guardian about any chronic or recent illnesses, injuries, hospitalizations, surgeries, or medical conditions. It also asks if the player is up to date on immunizations or has any allergies. The second part is completed by a physician who evaluates the player's height, weight, blood pressure, and conducts a physical examination. The physician then indicates whether sports participation is approved and if there are any limitations.

1. Name: ________________________________________
Date of Birth: _______________
Bloomsburg Midget
Football
Sports Evaluation
Age: __________
Health History
A Parent/Guardian should provide the following information:
Yes
No
Chronic/Recent illness?
Hospitalization?
Surgery?
Injury?
Bone/Joint Injuries?
Missing Organs?
Dizziness/Fainting/Convulsions?
Frequent headaches?
Knocked out/concussions?
Wear glasses or contacts?
Hearing problems?
Asthma/chronic cough?
Hernia?
Recurrent skin disease?
Current Medications? List….
Must be completed AFTER June 1st
A PHYSICIAN SHOULD COMPLETE THIS SIDE.
COMMENTS
Height
Weight
BP
Satisfactory
Yes
No
NE
General
Head
Eyes
ENT
Chest
Heart
Abdomen
Genitalia
Skin
Ortho.
Flex/Strength
Follow-up recommendations:
Allergy to medications? List….
Family history of heart disease or
unexpected death at young age?
Other family history of disease?
Immunizations current?
Date of last Tetanus: _________________________
***The above is true and correct to the best of
my knowledge.
______________________________________
Parent/Guardian Signature
Date: ________________________________
Sports participation approved:
Yes: _____ No: _____ Restricted: _____
Limitations:
__________________________________
Physician Signature
Date: ____________________________