Athletic Physical Form
Athletic Physical Examination Form
Name: ___________________________________ Birth Date: __________________ Gender: M F Grade: __________________ School: __________________________ Sport: _____________________ Address: ____________________________________________ Home Phone: _____________________ Father's Name: ________________________________________ Daytime Phone: __________________ Mother's Name: _______________________________________ Daytime Phone: __________________ Additional Emergency Contact Person (in the event neither parent can be reached): Name: __________________________ Relation: ______________ Daytime Phone: ________________
Medical History
Any significant past injuries Allergies, asthma, or wheezing Contact lenses or glasses Currently on medication/medications Chronic illness Allergies
Yes No
Hospitalizations or surgeries Seizures Head injuries or concussions Bone or joint injuries Current on all vaccinations Other:
Yes No
Comments: ___________________________________________________________________________ _____________________________________________________________________________________
Physical Exam
Ears Nose Throat Eyes Skin Dental/Mouth Lungs
Result Comments
Result Comments
Neurological Genito-urinary Gastrointestinal Spinal Mental Health Cardiovascular Musculoskeletal
Final Diagnosis: ________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
I approve this student's participation in an interscholastic sport for one year.
Yes
No
Physician/PNP Name: ___________________________________________________________________ Physician/PNP Signature: ________________________________________________ Date: ___________
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