Fighter Pre-Bout Physical Form

ISCF FIGHTER PRE-BOUT PHYSICAL FORM

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FIGHTERS FULL NAME

AGE: _______ - DOB: ______/______/______

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Event Date: ______/______/______
Event Promoter: _______________________
Event City: __________________________
Event State: __________________________
Event Country: _______________________

FIGHTER: Please answer ALL of the following Questions Before your fighter physical check below
PLEASE CHECK YES or NO At Right To The Following Questions	YES	NO
Do you have medical insurance?	_________	_________
Any chronic medical conditions? (Diabetes, asthma, heart condition etc.)	_________	_________
If chronic medical conditions Please Explain:
Ever had any surgery	_________	_________
If Had Surgery Please Explain:
Ever been Hospitalized?	_________	_________
If Hospitalized Please Explain:
Ever had a fracture or dislocation? If yes, when? ____/____/____	_________	_________
Ever had a sprain or strain requiring special equipment or braces? If yes, when? ___/___/___	_________	_________
Any vision problems?	_________	_________
Do you wear contact lenses?	_________	_________
Have you ever passed out while exercising? If yes, when? ____/____/____	_________	_________
Have you ever had chest pains while exercising? If yes, when? ____/____/____	_________	_________
Have you ever felt dizzy while exercising? If yes, when? ____/____/____	_________	_________
Have you ever had wheezing or coughing while exercising? If yes, when? ____/____/____	_________	_________
Have you ever been told you have high blood pressure?	_________	_________
Ever feel as though your heart is skipping beats or have runs of irregular rhythm?	_________	_________
Have you ever been told you have a heart murmur?	_________	_________
Any family members die suddenly before the age of 50?	_________	_________
Do you have a congenital defect such as single kidney, undescended testicle, cardiac defect?	_________	_________
Do you have any hernias, groin or abdominal?	_________	_________
Have you ever had a head injury or concussion? If yes, when? ____/____/____	_________	_________
Have you ever been knocked unconscious? If yes, when? ____/____/____	_________	_________
Have you ever had a pinched nerve or numbness or tingling in your arms, hands or feet?	_________	_________
Have you ever had a heat stroke? If yes, when? ____/____/____	_________	_________
Do you have any drug allergies? If yes, what:	_________	_________

Fighters Signature: ____________________ Print Name:__________________ Date: ___/___/___

MEDICAL QUESTIONS: Doctor, Paramedic or Nurse Only Below This Line

Physical Check

RESULT

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Physical Check

RESULT

Fighters Weight

_________

Fighters Eyes

_________

Fighters Age

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Fighters Heart

_________

Fighters Pulse

_________

Fighters Lungs

_________

Fighters Blood Pressure

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Fighters Hernia/Abd.

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Fighters Hands

_________

Physical Look

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D/P/N Signature: ____________________ Print Name:__________________ Date: ___/___/___