Pre-fight History and Physical
Full Name (last, first, MI) _________________________ Date of Birth________
Date of Last Bout _________________ Result ___________
Name, Address, And Telephone Number of a person to contact in case of emergency:
___________________________________________
___________________________________________
Have You Ever Been Knocked Unconscious? Yes No
If "yes" list date ____________
Have You Had Any Serious Bone Or Joint Injuries? Yes No
If “yes” explain:__________________________________
Have You Ever Had A Concussion Or Head Injury Of Any Type? Yes No
Have You Ever Passed Out During Exercise? Yes No
Are You Currently Being Treated For Any Illness? Yes No
Are You Currently Taking Any Medicines On A Regular Basis? Yes No
Have You Ever Been Treated For Any Serious Illness? Yes No
If “yes” explain:__________________________________
__________________________________
Are You Allergic To Any Medicines? Yes No
Are You Currently, Or Have You Ever Used Anabolic Steroids? Yes No
Have You Ever Had Radial Keratotomy Eye Surgery? Yes No
Do You Have Any Underlying Medical Conditions? Yes No
Have You Ever Had Surgery? Yes No
If “yes” explain and include dates:____________________
_______________________________________________
Were you Knocked Out in your last bout? Yes No
(WOMEN ONLY) Is There Any Chance That You Are Pregnant? Yes No
When was your last menstrual cycle?____________
(WOMEN ONLY) Have You Ever Had Breast Augmentation? Yes No
Signature Of Participant: _______________________________________
Printed name of Participant:_____________________________________
Date:__________________
TO BE COMPLETED BY EXAMINING PHYSICIAN
Blood Pressure: ____/ ____
Pulse: _______
Respirations: _________
Head Acceptable Noted_______________________
Eyes Acceptable Noted_______________________
Ears Acceptable Noted_______________________
Nose Acceptable Noted_______________________
Throat Acceptable Noted_______________________
Lungs Acceptable Noted_______________________
Chest Acceptable Noted_______________________
Heart Acceptable Noted_______________________
Abdomen Acceptable Noted_______________________
Orthopedic Acceptable Noted_______________________
Neurological Acceptable Noted_______________________
Pregnancy Test (if Applicable): Positive Negative
Notes: ______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
I, hereby certify, based on the participant's statements above, and my findings, it is my opinion that this participant is in good
physical condition and is considered; Medically Fit to engage in amateur mixed martial arts competition on the below noted date.
Date________20___
Physician Signature:___________________________
Printed Name:________________________________
Full Name (last, first, MI) _________________________ Date of Birth________
Date of Last Bout _________________ Result ___________
Name, Address, And Telephone Number of a person to contact in case of emergency:
___________________________________________
___________________________________________
Have You Ever Been Knocked Unconscious? Yes No
If "yes" list date ____________
Have You Had Any Serious Bone Or Joint Injuries? Yes No
If “yes” explain:__________________________________
Have You Ever Had A Concussion Or Head Injury Of Any Type? Yes No
Have You Ever Passed Out During Exercise? Yes No
Are You Currently Being Treated For Any Illness? Yes No
Are You Currently Taking Any Medicines On A Regular Basis? Yes No
Have You Ever Been Treated For Any Serious Illness? Yes No
If “yes” explain:__________________________________
__________________________________
Are You Allergic To Any Medicines? Yes No
Are You Currently, Or Have You Ever Used Anabolic Steroids? Yes No
Have You Ever Had Radial Keratotomy Eye Surgery? Yes No
Do You Have Any Underlying Medical Conditions? Yes No
Have You Ever Had Surgery? Yes No
If “yes” explain and include dates:____________________
_______________________________________________
Were you Knocked Out in your last bout? Yes No
(WOMEN ONLY) Is There Any Chance That You Are Pregnant? Yes No
When was your last menstrual cycle?____________
(WOMEN ONLY) Have You Ever Had Breast Augmentation? Yes No
Signature Of Participant: _______________________________________
Printed name of Participant:_____________________________________
Date:__________________
TO BE COMPLETED BY EXAMINING PHYSICIAN
Blood Pressure: ____/ ____
Pulse: _______
Respirations: _________
Head Acceptable Noted_______________________
Eyes Acceptable Noted_______________________
Ears Acceptable Noted_______________________
Nose Acceptable Noted_______________________
Throat Acceptable Noted_______________________
Lungs Acceptable Noted_______________________
Chest Acceptable Noted_______________________
Heart Acceptable Noted_______________________
Abdomen Acceptable Noted_______________________
Orthopedic Acceptable Noted_______________________
Neurological Acceptable Noted_______________________
Pregnancy Test (if Applicable): Positive Negative
Notes: ______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
I, hereby certify, based on the participant's statements above, and my findings, it is my opinion that this participant is in good
physical condition and is considered; Medically Fit to engage in amateur mixed martial arts competition on the below noted date.
Date________20___
Physician Signature:___________________________
Printed Name:________________________________
