NTERIM QUESTIONNAIRE the ineecolsic (213 aie peng in he Tis eg al stale compte itor an hse examination pr ib fn a ge pra Pippa, psc ea Sane Aust Marlowe Dee et tfielos Gyr Address: 300 _[c: mb. 208-§ sts - 5250 Schoot Thunder Ridge pes Grade MEDICAL HISTORY SINCE LAST PHYSCAL EXAMINATION, HAS THIS STUDENT: Flin details of "YES" answers in space below: Ye No 1. Had snger? 2. Been horialzed? 5. Beem undera pyri care 4. ad sei toes? 5 Had an injury requiring 3 physician's ar? 6, Been endered unconscious? 7. Been diagnosed with a concussion? 8. Started taking any new medications? 9. Developed any new deg alleges? ooo0cGgo000 WEEEHE SKEW 10 Developed any heath problems? Exp "YES" answers CONSENT FORM (en or guiion and eer prisons por) cc nnd set prcpaigin deinen ln ei hwnd fem, Th cone ince tel and fm bese My ee ‘should or Cshould NOT have a physical examination prior to participation in high school athletics. ame__Dawn Marlowe Ades B00 Kate Zip_ 33406 iy: __ Arm ne. ks Phone:__208-S29-93¢3 TORGUARDIANSIGNATURE CD Y¥icu, Dapacdanere ____ pare PxRE igh eral pn hc See Asc sicnsruns orstupent_ tedden (// leetsne — ‘Note: ‘The original copy of this form MUST be returned to the school