Get Da Form 7725

INSTRUCTIONS for Health Assessment complete sections A C Sports Physicals complete sections A B C. PART A NAME OF SPONSOR TELEPHONE HOME CELL SPONSOR UNIT / WORK ADDRESS TELEPHONE DUTY SPONSOR SSN SPOUSE S WORK PHONE CHILD HEALTH INFORMATION NAME OF CHILD BIRTH DATE DOES YOUR CHILD HAVE ON GOING MEDICAL CONCERNS YES SEX MALE FEMALE IF YES EXPLAIN CIRCUMSTANCES AND CURRENT STATUS NO IS YOUR CHILD ENROLLED IN EXCEPTIONAL FAMILY MEMBER PROGRAM YES MEDICAL HISTORY YES NO 1. CHILD AND YOUTH SERVICES HEALTH ASSESSMENT / SPORTS PHYSICAL DATA REQUIRED BY THE PRIVACY ACT OF 1994 PRINCIPAL PURPOSE Information is used by DA personnel to 1 verify child health status of immunization per admission requirements 2 note special program considerations or restriction on child participation 3 execute emergency medical procedure for chronic illnesses/conditions 4 refer child for enrollment in Exceptional Family Member Program 5 certify physically fit to participate in sports. ROUTINE USES No information is disclosed outside DOD. DISCLOSURE Information is voluntary however if information is not provided individuals may not be able to participate in community activities. ANY HOSPITALIZATION OR OPERATIONS 2. ALLERGIES TO MEDICINE INSECT BITES or FOOD 3. SPEECH OR DEVELOPMENT DELAYS 4. VISION PROBLEMS GLASSES / CONTACTS 5. EAR OR HEARING PROBLEMS 6. SEIZURES OR CONVULSIONS 7. DIZZINESS OR FAINTING WITH EXERCISE 8. HEADACHES 9. HEAD INJURY OR LOSS OF CONSCIOUSNESS 10. NECK OR BACK INJURY 11. ASTHMA OR DIFFICULITY BREATHING 12. HEART OR BLOOD PRESSURE PROBLEMS 13. CHEST PAIN WITH EXERCISE 14. HEAT STROKE OR EXHAUSTION 15. BROKEN BONES OR SPRAINS 16. JOINT INJURIES ANKLE / KNEE / WRIST 17. REQUIRED RESTRICTED PHYSICAL ACTIVITY 18. DIABETES 19. CANCER 20. DENTAL OR ORTHODONTIC BRACES 21. LEARNING PROBLEMS 22. SLEEP PROBLEMS 23. BEHAVIORAL PROBLEMS 24. ADD / ADHD 25. OTHER PROBLEMS LIST BELOW IF YOU ANSWER YES TO ANY OF THE ABOVE PLEASE EXPLAIN ON-GOING MEDICATIONS NAME DOSAGE ALLERGIES ALL TYPES FOODS MEDICINES INSECTS TYPE REACTION FREQUENCY PART B SPORTS PHYSICAL MEDICAL STAFF ASSESSMENT FILLED OUT BY LICENSED INDEPENDENT PRACTIONER AGE YRS / P HEIGHT ile VISUAL ACUITY NORMAL cm* RIGHT BP MOS / LEFT N/A kgs. / TESTED WITH / WITHOUT GLASSES COMMENTS 1. EYES 2. EARS NOSE THROAT 3. HEARING 4. MOUTH TEETH 5. NECK SOFT TISSUES 6. CARDIOVASCULAR 7. CHEST LUNGS 8. ABDOMEN 9. GENITALIA HERNIA 10. SKIN LYMPHATICS 11. SPINE SCOLIOSIS 12. EXTREMITIES 13. NEUROLOGICAL 14. WEARS BRACES / PLATES BASED ON THIS HX PX EXAM THE FOLLOWING ABNORMALITIES WERE FOUND AND MAY NEED TREATMENT IMMUNIZATIONS ARE CURRENT AND UP TO DATE PARTICIPATION RECOMMENDATIONS All sports Yes No Normal physical activity to including PE TA Additional comments Restrictions SPORTS PHYSICAL IS VALID FOR 1 YEAR FROM DATE INDICATED BELOW PART C SPECIAL MEDICAL CONSIDERATIONS Describe any special program needs considerations or restrictions which the child requires in order to participate in CYS Programs to include Sports CHILD / YOUTH IS ABLE TO PARTICIPATE IN NORMAL CYS PROGRAMS DATE LICENSED HEALTH CARE PROFESSIONAL STAMP LICENSED HEALTH CARE PROFESSIONAL SIGNATURE TYPE OR PRINT NAME OF PARENT OR GUARDIAN SIGNATURE OF PARENT OR GUARDIAN DATE RE-CERTIFICATION SIGNATURE PARENT/GUARDIAN DATE HAS HEALTH STATUS CHANGED YES.