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Fill in Your Mississippi Sports Medicine Athletics Physical Template

The Mississippi Sports Medicine Athletics Physical form is a crucial document designed for student-athletes participating in sports. This form collects essential health information, ensuring that young athletes are fit for participation and helps identify any potential medical issues. To ensure a smooth process, please fill out the form by clicking the button below.

Make This Mississippi Sports Medicine Athletics Physical

Fill in Your Mississippi Sports Medicine Athletics Physical Template

Content Overview

The Mississippi Sports Medicine Athletics Physical form is an essential document designed for student-athletes participating in school sports. This form collects critical information to ensure the safety and health of each athlete. It begins with basic personal details, including the athlete's name, date of birth, school, grade, and the sports they intend to participate in. Additionally, it gathers information about the athlete's family medical history, highlighting any hereditary conditions that may pose risks during athletic activities. The form also addresses the athlete's orthopedic history, detailing any past injuries and surgeries that could affect their performance. Furthermore, it includes a section on the athlete's medical history, where they must disclose any existing health issues, medications, or allergies. The form culminates with a waiver, acknowledging the limited nature of the physical examination and granting permission for the evaluation. Importantly, it emphasizes that the screening is not a guarantee against injury or sudden death, reinforcing the need for ongoing health awareness. This comprehensive approach aims to protect the well-being of student-athletes while promoting a safe sporting environment.

Mississippi Sports Medicine Athletics Physical Preview

DO NOT FOLD FORM

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER/UNIVERSITY SPORTS MEDICINE

ATHLETIC PARTICIPATION FORM

Please Print

Name __________________________________________________________________________________ Date ____________________________

School _______________________________________________________ Grade ___________ Sport(s) __________________________________

Sex: M F Date of Birth ______________________________ S.S.N. __________________________________________________ Age ________

Parent/Guardian Name __________________________________________________________________ Work Phone ________________________

Address _____________________________________________________________________________ Home Phone ________________________

Family Physician _______________________________________________________________________ Work Phone ________________________

			FAMILY MEDICAL HISTORY
			Has any member of your family under age 50 had these conditions?
Yes	No	Condition	Whom
		Heart Attack	___________________________________________________________________________
		Sudden Death	___________________________________________________________________________
		Stroke	___________________________________________________________________________
		Heart Disease / High Blood Pressure ___________________________________________________________________________
		Diabetes	___________________________________________________________________________
		Sickle Cell Anemia	___________________________________________________________________________
		Arthritis	___________________________________________________________________________
		Epilepsy	___________________________________________________________________________
		Kidney Disease	___________________________________________________________________________
			ATHLETE’S ORTHOPAEDIC HISTORY
			Has the athlete had any of the following injuries?
Yes	No	Condition	Date	Yes	No	Condition	Date
		Shoulder L / R	_____________________			Neck Injury / Stinger	____________________
		Elbow L / R	_____________________			Arm / Wrist / Hand L / R	____________________
		Hip	_____________________			Back	____________________
		Knee L / R	_____________________			Thigh L / R	____________________
		Chronic Shin Splints L / R	_____________________			Lower Leg L / R	____________________
		Foot L / R	_____________________			Ankle L / R	____________________
		Pinched Nerve	_____________________			Severe Muscle Strain	____________________
						Chest	____________________

Previous Surgeries: ________________________________________________________________________________________________________

ATHLETE’S MEDICAL HISTORY

Has the athlete had any of these conditions?
Yes	No	Condition	Yes	No	Condition	Yes	No	Condition
		Heart Murmur			Organ Loss			Overnight in hospital
		Seizures			Shortness of breath / coughing			Hernia
		Kidney Disease			during exercise			Rapid weight loss / gain
		Irregular Pulse			Chest Pain/Tightness			Take supplements / vitamins
		Single Testicle			Loss of consciousness/"Knocked out"			Heat related problems
		High Blood Pressure			Heart Disease			Menstrual irregularities
		Dizzy / Fainting			Diabetes			Recent Mononucleosis /
		Head Injury / Concussion			Liver Disease			Enlarged Spleen
		Asthma			Tuberculosis

 Have you had any serious medical illness/injury since your last sports physical? _____________________________________________

 Are you currently taking any prescription or non prescription (over the counter) medicaitons? ___________________________________

 Surgery - What Type? ___________________________________________________________________________________________

 Allergies (Food, Drugs) __________________________________________________________________________________________

Date of last Tetanus Immunization ____________________________________________________________________________________________

To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals provid- ing services may be immune from liability under Mississippi Law.

WAIVER FORM

This waiver, executed this ________ day of ___________________, 20____, by ______________________________________________ , M.D.

and ________________________________________, patient, is executed in compliance with Mississippi law, with the full understanding that if a phy-

sician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.

__________________________________________________					_________________________________________________________________
Signature of Patient					Typed or Printed Name of Physician
__________________________________________________					_________________________________________________________________
Signature of Parent/Guardian (Not required if patient is over 18 yrs old.)					Signature of Physician
			INFORMATION BELOW TO BE FILLED OUT BY PHYSICIAN ONLY
Height ______________________			Weight ____________________ Blood Pressure __________________ Pulse ____________________________
ORTHOPAEDIC EXAM				GENERAL MEDICAL EXAM
		Norm	Abnl			Norm	Abnl		Norm	Abnl
I.	Spine / Neck	________	________	ENT		________	________	Lungs	________	________
	Cervical	________	________	Heart		________	________	Abdomen	________	________
	Thoracic	________	________	Skin		________	________	Hernia (if Needed) ________		________
	Lumbar	________	________	General Health Comments ____________________________________________________
II.	Upper Extremity	________	________	__________________________________________________________________________
	Shoulder	________	________	__________________________________________________________________________
	Elbow	________	________	FLEXIBILITY		LEFT	RIGHT	FLEXIBILITY	LEFT	RIGHT
	Wrist	________	________	Neck		________	________	Shoulders	_________	________
	Hand / Fingers	________	________	Hips		________	________	Quadriceps	________	________
III.	Lower Extremity	________	________	Hamstrings		________	________	Achilles	________	________
	Hip	________	________	Back Ext / Flex		________	________
	Knee	________	________	Comments _________________________________________________________________
	Ankle	________	________	__________________________________________________________________________
	Feet	________	________	__________________________________________________________________________

Other Comments __________________________________________________________________________________________________________

OPTIONAL EXAMS
DENTAL	VISION L ________ R ________
Comments ___________________________________________	Comments: ____________________________________________________
____________________________________________________	_____________________________________________________________

Comments _______________________________________________________________________________________________________________

[	]	From this limited screening I see no reason why this student cannot participate in athletics
[	]	Student needs further evaluation as described

Get Mississippi Sports Medicine Athletics Physical File

File Features

Fact Name	Description
Form Title	The form is officially titled the "University of Mississippi Medical Center/University Sports Medicine Athletic Participation Form."
Purpose	This form is designed to collect essential medical and personal information to ensure the safety and health of student athletes participating in sports.
Family Medical History	It requires information regarding the family medical history of conditions such as heart disease, diabetes, and stroke, specifically focusing on relatives under the age of 50.
Athlete's Medical History	The form includes a section where athletes disclose any past medical conditions, surgeries, or injuries, ensuring a comprehensive understanding of their health status.
Waiver of Liability	A waiver is included, which grants immunity from liability to physicians providing voluntary medical services, in accordance with Mississippi law.
Physician's Section	There is a dedicated section for physicians to fill out, which includes vital statistics like height, weight, and blood pressure, along with a general medical examination assessment.

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