Physical Examination for Sports Participation
|
NAME |
MALE FEMALE |
|||||
|
ADDRESS |
||||||
|
CITY |
STATE |
|
||||
|
HOME PHONE
PARENT CELL |
DATE OF BIRTH |
AGE |
GRADE |
|||
NOTE: The following section must be filled in by an authorized medical practitioner:
|
SIGNIFICANT MEDICAL CONDITIONS |
|||
|
|
YES |
NO |
IF YES, EXPLAIN |
|
ALLERGIES |
|
|
|
|
ASTHMA |
|
|
|
|
CARDIAC |
|
|
|
|
CHEMICAL DEPENDENCY |
|
|
|
|
DRUGS/ALCOHOL |
|
|
|
|
DIABETES MELLITUS |
|
|
|
|
GASTROINTESTINAL DISORDER |
|
|
|
|
HEARING DISORDER |
|
|
|
|
HYPERTENSION |
|
|
|
|
NEUROMUSCUALR DISORDER |
|
|
|
|
ORTHOPEDIC CONDITION |
|
|
|
|
RESPIRATORY ILLNESS |
|
|
|
|
SEIZURE DISORDER |
|
|
|
|
SKIN DISORDER |
|
|
|
|
VISION DISORDER |
|
|
|
|
OTHER(SPECIFY) |
|
|
|
|
CURRENT MEDICATIONS |
|
|
|
|
REPORT OF PHYSICAL EXAMINATION |
|||
|
|
NORMAL |
ABNORMAL |
IF ABNORMAL, EXPLAIN |
|
HEIGHT(Inches) |
|
|
|
|
WEIGHT(Pounds) |
|
|
|
|
PULSE( ) |
|
|
|
|
BLOOD PRESSURE / |
|
|
|
|
HAIR/SCALP |
|
|
|
|
SKIN |
|
|
|
|
EYES- VISUAL ACUITY R / L / |
|
|
|
|
EYES- COLOR VISION |
|
|
|
|
EARS-HEARING |
|
|
|
|
NOSE AND THROAT |
|
|
|
|
TEETH AND GINGIVA |
|
|
|
|
LYMPH GLANDS |
|
|
|
|
HEART – MURMUR |
|
|
|
|
LUNG-ADVENTIOUS |
|
|
|
|
ABDOMEN |
|
|
|
|
GENITALIA |
|
|
|
|
NEUROMUSCULAR SYSTEM |
|
|
|
|
EXTREMITIES |
|
|
|
|
SPINE (PRESENCE OF SCOLIOSIS) |
|
|
|
|
IMMUNIZATIONS (UP TO DATE) |
YES |
NO |
|
DATE OF EXAMINATION__________________ Cleared to play all sports ______ Non-Contact Only ______
The Physicians form may be substituted for this form, this is a sample of areas expected to be examined for clearance. PLEASE RETURN THIS FORM TO THE ATHLETIC TRAINER, ATHLETIC DIRECTOR OR SCHOOL NURSE TO TRYOUTS.
SIGNATURE OF EXAMINER____________________________________________________________