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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