A school sponsored physical will be offered at Hull High School on Friday, August 8th at 8AM in the nurse's office. The questionnaire below must be returned to Mrs. Roach, at Hull High School (180 Main Street/troach@town.hull.ma.us) before July 31 to ensure that your child will be examined. If you have questions, please contact Nurse Roach at 78.925.3000 ex 1102 or her email listed above. Additional questions can be sent to Jim Quatromoni, Director of Athletics at 781.925.3000 ex 1113 or jquatromoni@town.hull.ma.us .
Physical
Information/Permission Sheet
Student’s Name:
_________________________________________________________________________
I give permission for my child, (write
name) __________________________________________________,
to have their physical exam done by
Dr. Martin Iser at Hull High School on August 8, 2014.
_______________________________________________ ___________________
Parent/Guardian Signature Date
Must be completed by parent/guardian prior to
physical exam
1. Please list any surgical procedures with age
and date: _________________________
___________________________________________________________________
___________________________________________________________________
2. List any
broken bones, sprains, muscle or tendon injuries with age and date: ________
___________________________________________________________________
___________________________________________________________________
3. Has the
student experienced any of the following?
Please circle yes or no.
Asthma Y N Hepatitis Y N
Allergies Y N Heart
Murmur Y N
Blood
Disorders Y N Heat
Stroke/Exhaustion Y N
Concussion Y N Kidney
Disease/Injury Y N
Diabetes Y N Seizure
Disorder Y N
Fainting/Convulsion Y N Other Serious
Illness Y N
Head Injury Y N Medication Y N
Glasses/Contacts Y N
Please explain
yes answers above: _______________________________________
___________________________________________________________________
___________________________________________________________________
Please list
any other health issues or concerns: ______________________________
___________________________________________________________________
___________________________________________________________________
I
have answered this medical questionnaire to the best of my knowledge.
_____________________________________ ___________
Parent/Guardian
Signature Date
