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Get NV SNYSA Middle School Football League Physical Form

(H): (W) Sex (circle): M F Birth date: Age: Health Insurance Carrier (primary): HEALTHY HISTORY (must be completed prior to examination) Has this Athlete had any: Is there any history of: YES NO YES NO Chronic or recurring illness Injuries requiring physician treatment Illness lasting over 1 week Neck or back injury Hospitalizations Knee injury Surgery other than removal of tonsils Shoulder or elbow injury Missing organs (eye, kidney, testicale) Ankle injury Allergies (medicines, insect bites, .

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