Officials Physical

West Virginia Secondary School Activities Commission
PHYSICAL EXAMINATION FOR OFFICIALS - Recommended Yearly

(To Be Completed by Official BEFORE Examination - Please Type or Print)

Name ________________________________ Reg. # ________________ Local Board __________________________
(Last) (First) (M)

Home Address ________________________________________________Telephone #_________________________

Business Address ___________________________________________Telephone #_________________________

Birth Date _____________________ SS # _______________________ Occupation ___________________________

Have you had in the last 2 years Do you:

Yes	No	1.	Chronic or recurrent illness? (Diabetes, Asthma, Seizures...)	Yes	No	11.	Have any allergies?
Yes	No	2.	Any hospitalizations?	Yes	No	12.	Have any problems with heart/blood pressure.
Yes	No	3.	Any surgery (Except tonsils)?	Yes	No	13.	Has anyone in your family ever fainted during exercise?
Yes	No	4.	Any injuries that prohibited your participation in sports?	Yes	No	14.	Take any medicine? List _______________________
Yes	No	5.	Dizziness or frequent headaches?	Yes	No	15.	Wear glasses ___, contact lenses ___, dental appliances___?
Yes	No	6.	Concussion/knocked out?	Yes	No	16	Have any organs missing (eye, kidney, testicle, etc.)?
Yes	No	7.	Knee, ankle, or neck injuries?	Yes	No	17.	Has it been longer than 10 years since your last tetanus shop?
Yes	No	8.	Broken bone or dislocation?	Yes	No	18.	Have you ever been told not to participate in any sport?
Yes	No	9.	Heat exhaustion/sun stroke?	Yes	No	19.	Do you know of any reason you should not participate in sports.
Yes	No	10.	Fainting or passing out?	Yes	No	20.	Have a sudden death history in your family?
PLEASE EXPLAIN ANY "YES" ANSWERS OR ANY OTHER ADDITIONAL CONCERNS.				Yes	.No	21	Have a family history of heart attack before age 50?
				Yes	No	22.	Develop coughing, wheezing, or unusual shortness of breath when you exercise?

I also give my consent for the physician in attendance and the appropriate medical staff to give treatment at any athletic event for any injury.

SIGNATURE OF OFFICIAL ________________________________________________________________DATE_______/_______/_______

PHYSICIAN NEEDS TO SIGN EITHER A OR B

(A) This person is my personal patient, and meets all the physical requirements for employment as an official where the work is exacting and involves considerable physical and nervous strain and a great deal of running to keep up with the game.

If not, remarks and corrective measures suggested should be EXPLAINED ON REVERSE SIDE.

Physician Signature ____________________________________________________ Date ________________________________

(B) PHYSICAL EXAM

Height _____________________ Weight ______________________ Pulse _____________________ Blood Pressure _____________________

Visual acuity: Uncorrected ________/_________; Corrected ________/________; Pupils equal diameter: Y N

HEENT - acceptable	Y	N	Cardiovascular:			Abdomen:
Carotid Bruits	Y	N	Murmur	Y	N	Masses	Y	N
Respiratory:			Irregularities	Y	N	Organomegaly	Y	N
Symmetrical breath sounds	Y	N	Murmur with valsalva	Y	N	Genitourinary (males only)
Wheezes	Y	N	Peripheral pulses equal	Y	N	Inguinal hernia	Y	N

Musculoskeletal: (note any abnormalities)
Neck	Y	N	Elbow	Y	N	Hip/Knee	Y	N
Shoulder	Y	N	Wrist	Y	N	Ankle	Y	N

RECOMMENDATION _________________________ LIMITED APPROVAL FOR SPECIFIC SPORT (list) ________________________

Physician Signature ____________________________________________________ Date ________________________________

Return to Local Secretary if member of Local Board. If no Local Board, mail directly to: WVSSAC, 2875 Staunton Turnpike, Parkersburg, WV 26104
DEADLINE: This form is due immediately before officiating any sport, or credit for that season will not be given.

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