Fighter Pre-Bout Physical Form

IKF FIGHTER PRE-BOUT PHYSICAL FORM

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FIGHTERS FULL NAME
AGE: _______ - DOB: ______/______/______

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2009
IKF WORLD CLASSIC
ORLANDO, FLORIDA, USA
JULY 24th, 25th & 26th, 2009

FIGHTER: Please answer ALL of the 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 equip. 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 a single kidney or 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

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Fighters Eyes

_________

Fighters Age

_________

Fighters Heart

_________

Fighters Pulse

_________

Fighters Lungs

_________

Fighters Blood Pressure

_________

Fighters Hernia/Abd.

_________

Fighters Hands

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Physical Look

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