Athletic Physical Form
Athletic Physical Form
Name:
Date:
Address:
Guardian 1:
Guardian 2:
Emergency Contact:
Age:
Sport(s):
Significant Previous Injuries:
Hospitalizations or Surgeries:
Bone or Joint Injuries:
Current Medications:
Past Medications:
Chronic Illness:
Allergies:
Vaccinations are Current:
Seizures:
Asthma:
Height:
Feature
General
Eyes
Nose
Dental/Mouth
Throat
Ears
Skin
Cardiovascular
Musculoskeletal
Neurological
Genitourinary
Gastrointestinal
Spinal
Nutritional Status
Mental Health
Grade:
Home Phone:
Work Phone:
Work Phone:
Phone No.:
No
No
No
No
No
No
No
Yes
No
No
Weight:
Medical History
Yes:
Yes:
Yes
Yes:
Yes:
Yes:
Yes:
No:
Yes
Glasses or Contact Lenses:
Yes
Fainting/Dizzy Spells:
Physical Exam
Blood Pressure:
Result
No
No
Yes
Yes
Comments
Additional Comments:
I approve this student¡¯s participation in interscholastic sports for one (1) year.
Yes
Physician:
Signature:
Date:
PNP:
Signature:
Date
No
................
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