Physical Examination for Sports Participation
NAME |
MALE FEMALE |
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ADDRESS |
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CITY |
STATE |
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HOME PHONE
PARENT CELL |
DATE OF BIRTH |
AGE |
GRADE |
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NOTE: The following section must be filled in by an authorized medical practitioner:
SIGNIFICANT MEDICAL CONDITIONS |
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YES |
NO |
IF YES, EXPLAIN |
ALLERGIES |
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ASTHMA |
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CARDIAC |
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CHEMICAL DEPENDENCY |
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DRUGS/ALCOHOL |
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DIABETES MELLITUS |
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GASTROINTESTINAL DISORDER |
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HEARING DISORDER |
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HYPERTENSION |
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NEUROMUSCUALR DISORDER |
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ORTHOPEDIC CONDITION |
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RESPIRATORY ILLNESS |
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SEIZURE DISORDER |
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SKIN DISORDER |
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VISION DISORDER |
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OTHER(SPECIFY) |
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CURRENT MEDICATIONS |
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REPORT OF PHYSICAL EXAMINATION |
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NORMAL |
ABNORMAL |
IF ABNORMAL, EXPLAIN |
HEIGHT(Inches) |
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WEIGHT(Pounds) |
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PULSE( ) |
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BLOOD PRESSURE / |
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HAIR/SCALP |
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SKIN |
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EYES- VISUAL ACUITY R / L / |
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EYES- COLOR VISION |
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EARS-HEARING |
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NOSE AND THROAT |
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TEETH AND GINGIVA |
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LYMPH GLANDS |
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HEART – MURMUR |
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LUNG-ADVENTIOUS |
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ABDOMEN |
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GENITALIA |
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NEUROMUSCULAR SYSTEM |
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EXTREMITIES |
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SPINE (PRESENCE OF SCOLIOSIS) |
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IMMUNIZATIONS (UP TO DATE) |
YES |
NO |
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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____________________________________________________________