wisToRY This page t be completed by sucdent and parentiuarcian Pre-Partielpation Physical Evaluation Name Tone Soriano Persona physician De Robert Millar Incase ofemergency, contact, race “4 sen00) Marth Pei 5 ‘Aasess ms eS ae sox MA Age Cus ond aie oti Locersie. Name S210 Seno Retstonshp FATHE MC prone ty SUTSL PHC cup 208-955" 1907 Explain "Yes" anowes below, Cae queso I y00 Goi know be newer 1. Have you had a medical lines or injury since DF 40. Doyou use any special protective or corrective ow your lst chac up o sports pyatt. Celpmantor deco tat arn unity used for your sort ‘Do you ave an ongoing revere ness? (a wr, —_srpetion(orenarple toes bac, spol neck, 2 Have you ever been howpatzed overight? © —_ eaormettn eaier on yourted ear a? Have yu ever had burp? ET 4. taveyeunadanypcberawinyeureyesorvaost of 2. Areyoucarenty taking any pesto or TG” Doyouveargiates contac orpozcie eyewear? AY tonpresrption {ove te cburin) eats of 12, Have yousverhada sprain, san, or owe aterinun/? SF ils ring an ale? Have you olen er fachred any ove, ordaocaee Uf ‘Have you ever taken any supplements or vitamins ow any joints? toned you gan ore weigh or improve Your Have younadanycier plone win paoraweting Ef car am in muscles, tendons, bones, or joints? 4. Doyounave ary serge (or exare to poe, ityen stock appropiate box and expan below. ‘medane, fod or singng nsccsy" Ghee Uppers Cl Hand CD Kove Have you ever ha arash or ves develop dung Gesx | G ebow”G Figer Shea crater excce? Pe |S. Have you ever passed out during or after exercise? Gl Shoulder =O Wiist G Thigh G Foot Have You ever boon ny dat oar earcee? 12, Doyeuwantbwein more crlessthanyousono? FO Have you ever had chest pln dingo tar eer? lai restnasyoneanennrensenen OO came ee 14. Doyeutetaresse out? aw fave you ever had rcng of your het or ppad (esa ne ae for most recat maize (sho): feweas? Tetanus Measles ove you had igh lod pressure o igh chokes? oqates Cskenpan eve heart maar? ove ro ewe be 0a FEMALES ONLY Has any family member or relative ied of heat problens orof sudden death before age 50? Have you had a severe vial infection (for example, ‘myoearts of mononucleosis) win te last monty? Has a physcian ever dened or resbicted your jatiopaton i spans fr any heart problers? 8. Do-you have any curent skin problems (fr example, ftching. rashes, ane, warts, fungus oF Bs? 7. Have you ever ada head injury or concussion? Have you ever been kxocked ou, become unconscious, ertost your Have you ever had a seizure? ‘Do you have frequent or severe headaches? Have you ever had nuznbness o ging i your arms, hands ops fet? Have you ever hada eSnger, bumer, or pinched nerve? Have you ever become i fom exercising inthe heat? Doyou cough, wheeze, or have rouble breathing ‘unng ora acavty? Doyauhave asta? Do you have seasonal atergies tat require medical weament? es oo coo moc co ROO Ooo Oooo oR RR RAR ORR RRO R ROKR A BRRR RO 16. Wen was your fret menstrual period? nen was your most recent menstual perod? How much ie do you usualy have om the stan of one parade slat of another? How many prods have you had nthe last yea? ‘wnat was the longest tie bebeeen periods in the ast year? alan vor" anewors have: I. hawt, $cosoral allersies, toate Liga pes clei Sg a eo tos Enon or mmen ov on me gocinagad et Soman Sacto ‘Scpuarectoewewamn Beg ome 11/10/22. anya Pion fp hos PO Netcan ede Sosy ra Wogan ea sn fr Spats tein and nercan Onecpab eae Spats Neds Paget Scanned with CamScannerze Pre-Participation Physical Evaluation (This page to be completed by physcian‘aurse pracitionerplysician assistant) pare or exam I-10 - 202: NAME DATE oF BIRTH OI --1 rect DF, weicur {12.Ar% sop Fat (optonay — 7-1), _ purse 54 ep122/ Tl VISION R207 L201 CORRECTED? Y___N_‘__ PUPILS: EQUAL, [UNEQUAL "Bi Sana aE oy te pre 7 Nit eared for iSpomt) Reason: 11315 Pembrooke Sqhare ‘Waldorf, MD, 2060 Endorsed by the MPBSAA (© 1997 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, ‘American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicne Page2 Scanned with CamScannerSoriano, Jonah B. 14y 10m M DoB: 01/08/08 Patient Immunization ~All Dates Immunizations Pesan eric DTaP Pedr inex Pentacel Téap ev Pentecel ‘inex Pedant. tb (PRP-OMP Pedvaxt) Pentacel HIBERDX POV'3 Prevar) Rotax Rota Teg (otavins ve, ppentavalent vaccine) MMR Measles Fubeta Mumps Vericota Hep A, (2 dose) Hav. Hep A, ped NOS: Hop B -Engertx Pedioric Meningococcal (MCV) Merveo) Meningococcal B Bexsero Meningococcal B ‘Trumenba HPV -Cervart HPV-Guardass HPV-Guardasi9 PVT - Flat pefiled 6 mo VEC -Foiave!prefiled 6 HepB (Adu) Intuenza (FLUMIST) ‘VEC ONLY (fuzone) 3- ‘eye VEC ONLY (Fhzone) under 30 PVT Fhuzone multidose 6 mot PVT - FhazonePrefulled 6 35mo \VFC ONLY (Ifuenza) Fluzone Quadivalnt Przer COVID Dose os08/08 ‘73 ov08i08 anaie ovoero8 covoeos 3108108 ‘ox0si08 omano ontarto owt79 ovosie8 si3i9 swoaas swoar20 Dose ‘art0r08 senov0s ov08/08 rar10708 yen008 onan onan 10122109 ovosies swow21 Patient Chart Report 19/10122 9:41 am Robert E. Miller MD, FAAP, PA Dose Dose Dose Dose + Dose Dose Dose owr7i09 48109 our7ie9 onont3 onat3 rao0s 01717109 oazgio —tor2100 OWt7!09 Contra yanaoe —o1t709 Page 1 of 2 Scanned with CamScannerSorlano, Jonah B. 14y 10m M DOB: 01/08/08 Patient Immunization ~- All Dates Immunizations Dose Dose. Others: Prvate Fhizone 635 yartome 0117709 rmonihs HINT latuenza vis, spite 102209 11727708 vis, It PRIVATE Fluor awowia wane FLULAVAL ram6/13 Patient Chart Report 41110122 9:41 am Robert E, Miller MD, FAAP, PA Dose Dose anmanto Page 2 of 2 Dose Doso Dose Dose. Scanned with CamScanner