Student Physical Examination Form - Activities/athletics
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1
2
3DISTRICT
PLEASANT VALLEY COMMUNITY SCHOOL
Student Physical Examination Form - Activities/Athletics
Last Name
First Name
Middle
Date of Birth
Age
Sex
Address
City
State
Zip
Parent/Guardian Name
Telephone
Cell Phone
Health History - To be completed by parent or guardian
Diseases/Chronic Illnesses
Allergies
Need Modifications
Asthma
Hay Fever
Medications
Chicken Pox
Insect Stings
Dietary
Heart Disease
Food
Special Equipment
Whooping Cough
Medications
Other
Seizures
Other
Diabetes
Hospitalizations:
Operations/Serious Illnesses:
Comments:
THIS SECTION TO BE COMPLETED BY PHYSICIAN
Optional
Optional
Height
Weight
BP
Pulse
Hearing
Vision
Urinalysis HCT/HGB
Date of last tetanus
Right
Left
Both
Normal
Comments
Normal
Comment
Skin
Genito-Urinary
Ears
Gastrointestinal/Abdomen
Eyes
Neurological
Nose/Throat
Musculoskeletal
Glands (Cerv)
Spinal Exam
Mouth/Dental
Nutritional
Cardiovascular
Girls-Menstrual Problems
Respiratory
Mental Health
Hernia
General Comments
If completing for athletic eligibility, please answer the following:
1. Is this athlete physically able to participate in Interscholastic Competition ?
Yes
No
2. Are there any restrictions placed on this athlete ?
3. General Condition:
Excellent
Good
Fair
Below average
Signature of Examining Physician
Date
Revised 12/2013
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