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Northern California USA Boxing Inc. BOXING PHYSICAL FORM Name Address D. O. B. Age City State Zip Code Phone HISTORY HAS APPLICANT EVER HAD ANY OF THE FOLLOWING SWOLLEN JOINTS YES NO RHEUMATISM FREQUENT HEADACHES CHRONIC COUGH SPITTING UP BLOOD CONVULSIONS SHORTNESS OF BREATH FAINTING SPELLS VENEREAL DISEASE DIZZY SPELLS WORN OR WEAR GLASSES/CONTACT LENSES BLURRING VISION DIABETIC EPILEPSY DEBILITATING DISEASE ORAL SURGERY Explain any YES answers IF YES LONGEST DURATION OF UNCONSCIOUSNESS ALSO PLEASE GIVE DATE AND PARTICULARS MILITARY SERVICE TYPE OF DISCHARGE IF REJECTED PLEASE GIVE REASON ANY HISTORY OF MENTAL ILLNESS IF YES EXPLAIN IN FULL ALLERGIC REACTIONS TO ANY MEDICATION EXPLAIN TAKING MEDICATION REGULARLY EXAMINATION GENERAL APPEARANCE HT. AGE PULSE AT REST BP AT REST DISABLING SCARS EYES VISION WITHOUT GLASSES RIGHT / LEFT PUPILS EQUAL REACT TO LIGHT EARS AUDITORY CANALS CLEAR TYMPANIC MEMBRANES NORMAL MOUTH TEETH TONSILS NECK ENLARGED GLANDS GOITER HEART PULSE RHYTHM REGULAR APICAL IMPULSE HEAVING NORMAL ENLARGEMENT MURMURS LUNGS CLEAR RALES ABDOMEN HERNIA FEMORAL INGUINAL VENTRAL GENITALIA DISCHARGE HANDS RECENT INJURY FRACTURES SWELLING UNHEALED WOUNDS REFLEXES PUPILS KNEE JERKS ROMBERG BABINSKIE SKIN RASH BOILS ANY OTHER REMARKS I HAVE THIS DAY OF EXAMINED THE ABOVE NAMED APPLICANT FINDING HIM/HER OF SATISFACTORY/UNSATISFACTORY PHYSICAL CONDITION TO BE CERTIFIED AS AN AMATEUR BOXER* I certify under penalty of perjury that the foregoing history is true and correct further I realize that any misstatement in said history will result in revocation or rejection of USA/BOXING passbook. NOTE It is the responsibility of the boxer to inform his/her coach and the ringside doctor pre-bout physical of any physical conditions s or problems which could affect the performance or well-being of the boxer or his/her opponents. PHYSICIAN S SIGNATURE ADDRESS CITY AND STATE SIGNATURE PARENT OR LEGAL GUARDIAN IF UNDER 18 YEARS OF AGE. AGE PULSE AT REST BP AT REST DISABLING SCARS EYES VISION WITHOUT GLASSES RIGHT / LEFT PUPILS EQUAL REACT TO LIGHT EARS AUDITORY CANALS CLEAR TYMPANIC MEMBRANES NORMAL MOUTH TEETH TONSILS NECK ENLARGED GLANDS GOITER HEART PULSE RHYTHM REGULAR APICAL IMPULSE HEAVING NORMAL ENLARGEMENT MURMURS LUNGS CLEAR RALES ABDOMEN HERNIA FEMORAL INGUINAL VENTRAL GENITALIA DISCHARGE HANDS RECENT INJURY FRACTURES SWELLING UNHEALED WOUNDS REFLEXES PUPILS KNEE JERKS ROMBERG BABINSKIE SKIN RASH BOILS ANY OTHER REMARKS I HAVE THIS DAY OF EXAMINED THE ABOVE NAMED APPLICANT FINDING HIM/HER OF SATISFACTORY/UNSATISFACTORY PHYSICAL CONDITION TO BE CERTIFIED AS AN AMATEUR BOXER* I certify under penalty of perjury that the foregoing history is true and correct further I realize that any misstatement in said history will result in revocation or rejection of USA/BOXING passbook. NOTE It is the responsibility of the boxer to inform his/her coach and the ringside doctor pre-bout physical of any physical conditions s or problems which could affect the performance or well-being of the boxer or his/her opponents. .

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