Get Football Physical Form

GWINNETT FOOTBALL LEAGUE PHYSICAL EXAMINATION FORM Year 2015 Name of Association I certify that I examined and recommend him/her to be physically able to compete in football contest. The following points wereparticularly checked and the condition noted as follows HEART Before exercise Immediately after exercise After brief period Blood Pressure Murmurs LUNGS Is there a history of Chronic cough Other condition Weight in its relation to height according to accepted chart such as B. T. Baldwin and G*D. Wood. Weight GENERAL CONDITION Excellent Below Par Date Good Fair Physician MD DO PA or NP only MEDICAL HISTORY completed by parent PAST HISTORY check all that apply Poliomyelitis Asthma Bone or joint Disease Heart Disease Diabetes Lung Disease Kidney Disease Head Injury Epilepsy or Convulsions Hearing Disorder Allergies explain Tetanus Booster may be given Yes No Do you wear contact lenses/glasses/hearing aid Explain AUTHORIZATION As a parent of I give specific permission for the GFL to have emergency medical treatment rendered to my child should my child be injured during the course of any GFL activity and agree that the physicians and/or medical providers who render such treatment do so with my specific authority. I further agree to pay all charges related to any such emergency medical treatment rendered to my minor child and agree to hold harmless and indemnify the GFL its member associations coaches and other officials from any and all responsibility for the payment of such medical expenses. I further agree as a parent of a child participating in the GFL to hold harmless and release the GFL its officers and directors its member associations its coaches and officials from any cause of action resulting from my child s participation my participation or any of my family members participation in any GFL activity. The following points wereparticularly checked and the condition noted as follows HEART Before exercise Immediately after exercise After brief period Blood Pressure Murmurs LUNGS Is there a history of Chronic cough Other condition Weight in its relation to height according to accepted chart such as B. T. Baldwin and G*D. Wood. Weight GENERAL CONDITION Excellent Below Par Date Good Fair Physician MD DO PA or NP only MEDICAL HISTORY completed by parent PAST HISTORY check all that apply Poliomyelitis Asthma Bone or joint Disease Heart Disease Diabetes Lung Disease Kidney Disease Head Injury Epilepsy or Convulsions Hearing Disorder Allergies explain Tetanus Booster may be given Yes No Do you wear contact lenses/glasses/hearing aid Explain AUTHORIZATION As a parent of I give specific permission for the GFL to have emergency medical treatment rendered to my child should my child be injured during the course of any GFL activity and agree that the physicians and/or medical providers who render such treatment do so with my specific authority. T. Baldwin and G*D. Wood. Weight GENERAL CONDITION Excellent Below Par Date Good Fair Physician MD DO PA or NP only MEDICAL HISTORY completed by parent PAST HISTORY check all that apply Poliomyelitis Asthma Bone or joint Disease Heart Disease Diabetes Lung Disease Kidney Disease Head Injury Epilepsy or Convulsions Hearing Disorder Allergies explain Tetanus Booster may be given Yes No Do you wear contact lenses/glasses/hearing aid Explain AUTHORIZATION As a parent of I give specific permission for the GFL to have emergency medical treatment rendered to my child should my child be injured during the course of any GFL activity and agree that the physicians and/or medical providers who render such treatment do so with my specific authority. I further agree to pay all charges related to any such emergency medical treatment rendered to my minor child and agree to hold harmless and indemnify the GFL its member associations coaches and other officials from any and all responsibility for the payment of such medical expenses.