Student-Athlete Physical Information

All student-athletes MUST have a valid physical within 13 months at all times during their season of participation.  If a student-athlete's 13 month window expires during a season, they will be ineligible to participate in games until a physical has been completed.  These requirements are closely monitored in conjunction with the state concussion protocol requirements.

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