General Medical Form - Department Of Veterans Affairs Page 2

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PHYSICAL FORM

HEART

WEIGHT

HEIGHT

LUNGS

SKIN

OTHER FINDINGS

PRESENT AND PAST MEDICAL HISTORY AND MAJOR OPERATIONS (Diabetes, heart disease, hypertension, etc.)

IS THE PATIENT ON DIALYSIS?* (Patient is responsible for setting up any dialysis treatment needed)

YES

IS THE PATIENT ON A VENTILATOR?

YES

IS THE PATIENT ON ANTICOAGULANT DRUGS? (If yes, which)

YES

PHYSICIAN CLEARANCE

In my opinion, the above individual is cleared to participate in the events they have indicated on their NVWG registration.

NVWG AND/OR USQRA CLASSIFICATION CARD(S)

PHYSICIAN INFORMATION

NON-VA

NAME OF EXAMINING PROVIDER (Please print) (Check appropriate box)

PLEASE ATTACH A COPY OF YOUR

ADDRESS (Street, City, State and Zip Code)

CLASSIFICATION CARD(S)

(See below)

SIGNATURE OF EXAMINING PROVIDER

If applicable, please attach a copy (not the original) of you

National Veterans Wheelchair Games, USQRA (quad rugby),

TELEPHONE NUMBER

DATE

and/or Wheelchair Sports, USA classification card above.

May omit only if copy of current NVWG Classification card is provided.

This section must be completed by someone familiar with direct muscle testing, i.e., a physician, physical therapist, kinesiotherapist, or occupational

therapist.

NEURO EXAM (Manual muscle test, 0-5)

UPPER EXTREMITY

RIGHT

LEFT

LOWER EXTREMITY

RIGHT

LEFT

DELTOID

HIP FLEXION

BICEPS

HIP EXTENSION