ALABAMA HIGH SCHOOL ATHLETIC
Name__________________________________________________ Sex ________
Age______ Date of birth _______________
__________ Sport ______________________
Explain "Yes" answers below:
1. Has a doctor ever restricted/denied
your participation in sports?
2. Have you ever been hospitalized or
spent a night in a hospital?
Have ever had surgery?
3. Do you have any ongoing medical
conditions (like Diabetes or Asthma)?
4. Are you presently taking any
medications or pills (prescription or
5. Do you have any allergies (medicine,
pollens, foods, bees or other stinging insects)?
6. Have you ever passed out during or
Have you ever been dizzy during or
Have you ever had chest pain or
discomfort in your chest during or after exercise?
Do you tire more quickly than your
friends during exercise?
Have you ever had high blood
Have you ever been told that you have a
heart murmur, high cholesterol, or heart infection?
Have you ever had racing of your heart
or skipped heartbeats?
Has anyone in your family died of heart
problems or a sudden death before age 50?
Does anyone in your family have a heart
Has a doctor ever ordered a test on
your heart (EKG, echocardiogram)?
7. Do you have any skin problems
(itching, rashes, staph, MRSA, acne)?
8. Have you ever had a head injury or
Have you ever been knocked out or
Have you ever had a seizure?
Have you ever had a stinger, burner,
pinched nerve, or loss of feeling or weakness in your arms or
9. Have you ever had heat or muscle
Have you ever been dizzy or passed out
in the heat?
10. Do you have trouble breathing or do
you cough during or after activity?
Do you take any medications for asthma
(for instance, inhalers)?
11. Do you use any special equipment
(pads, braces, neck rolls, mouth guard, eye guards, etc.)?
12. Have you had any problems with your
eyes or vision?
Do you wear glasses or contacts or
protective eye wear?
13. Have you had any other medical
problems (infectious mononucleosis, diabetes, infectious diseases,
14. Have you had a medical problem or
injury since your last evaluation?
15. Have you ever been told you have
sickle cell trait?
Has anyone in your family had sickle
cell disease or sickle cell trait?
16. Have you ever sprained/strained,
dislocated, fractured, broken or had repeated swelling or other
injuries of any bones or joints?
Head Back Shoulder Forearm Hand Hip
Neck Chest Elbow Wrist Finger Thigh
17. When was your first menstrual
When was your last menstrual
What was the longest time between your
Explain "Yes" answers:
I hereby state that, to the best of my
knowledge, my answers to the above questions are correct.
Signature of athlete
Signature of parent/guardian
__________________________________________________ DUPLICATE AS
Rev. 2010 FORM 5 Page 1 of
2- In order for a student to be eligible for
interscholastic athletics, there must be
Rule 1, Sec. 14
on file in the Superintendent's or
Principal's office a current physician's statement certifying
the student has passed a physical exam,
and that in the opinion of the examining physician (M.D.
or D.O.) the student is fully able to
participate in interscholastic athletics (Grade s 7‐12).
AHSAA Physicians Certificate (Form 5)
must be used. A physical exam will satisfy the
B. Cleared after completing
C. Not cleared for: Collision
Noncontact ____ Strenuous ____
Moderately strenuous ____ Nonstrenuous
Name of physician
Signature of physician
Height ____________ Weight
_____________ BP _____ / _____ Pulse ____________
Vision R 20 / ____ L 20 / ____
Corrected: Y N
Normal Abnormal Findings
requirement for one calendar year
through the end of the month from the date of the exam.
For example, a physical given on May 5,
2015, will satisfy the requirment through May 31, 2016.