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Health Services4245 East Avenue-Rochester, NY 14618Ph 585-389-2500 Fax 585-389-2503 PHYSICAL EXAM is Required for All Intercollegiate Athletes (NCAA), including Dance Team and JV Soccer **Physical must be within six(6) months of the start of in-season or non-traditional season practice Sickle Cell Testing is an NCAA requirement.?Attach testing results (newborn or recent). For information and waiver option, go to website . TO BE COMPLETED BY HEALTH CARE PROVIDERName_____________________________________ Date of Birth _____________________ Sport_________________Ht.________Wt. _______B/P ___________ HR ________ Medication Allergies _______________________________Current Medications Required______________________________________________________________________Check each item in the proper column. Enter NE if not examined.Normal AbnormalDescriptionHEENTNeck (Thyroid)Lungs, ChestC a r d io vascularAbdomen (Including Hernia)Genito-ur inary SystemExtremitiesSpine, Musculo-skeletalSkin and LymphaticsNeurologic (Specify disorder)Is the student currently under treatment for any medical or emotional/psychiatric condition? Yes_____ No _____Expalnation:_______________________________________________________________________________________Is there absence or seriously impaired function of any paired organ? Yes_____ No______Explanation:_______________________________________________________________________________________Are there any limitations/ restrictions? Yes_____ No______ Explanation:_______________________________________________________________________________________ Upon completion of their physical examination, I have found this student capable of participating in a full program of Intercollegiate Athletics365760-9525004690745-952500Health Care Provider Signature Date455930015875000365760-1143000Printed Name S t a m p365760-146050036576030670500Address365760-1016000Phone Fax Ck5.2015 ................
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