Athletic Medical Evaluation Form - 2016-2017 Page 2
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214. When was you last tetanus shot? ________________________________________________________________________
When was your last measles shot? ______________________________________________________________________
15. When was your first menstrual period? ___________________________________________________________________
When was you last menstrual period? ____________________________________________________________________
When was the longest time between your periods last year? __________________________________________________
____________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Signature of Athlete
Signature of Parent/Guardian
Date
Height _______________
Weight _______________
BP ___________ / __________
Pulse ______________________
Vision R 20/ _____________
L20/ _____________
Corrected?
Yes
No
Pupils _____________________
Ears, Nose, Throat
________________________________________________________________________________
Heart
________________________________________________________________________________
Chest / Lungs
________________________________________________________________________________
Skin / Lymphatics
________________________________________________________________________________
Abdominals
________________________________________________________________________________
Genitalia / Hernia
________________________________________________________________________________
Musculoskeletal Examination
Examiner ____________________________________
Neck / Back
________________________________________________________________________________
Upper Extremities
________________________________________________________________________________
Lower Extremities
________________________________________________________________________________
Flexibility
________________________________________________________________________________
Official Recommendation
A. This athlete
may
may not
compete in athletics based on the data gathered from this exam.
B. Prior to participation, treatment or follow-up on the following is recommended: __________________________________
______________________________________________________________________________________________________
C. Recommend further consultation with: ___________________________________________________________________
Signature of Physician ______________________________________________ Date _______________________________
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