Preparticipation Physical Evaluation - Medical History Page 2
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REPARTICIPATION
HYSICAL
VALUATION
HYSICAL
XAMINATION
Student's Name _________________________________ Sex _______ Age _______ Date of Birth _________________________
Height ______
Weight________
% Body fat (optional) ________
Pulse __________
BP____/____ (____/____, ____/____)
brachial blood pressure while sitting
Vision: R 20/______ L 20/___
Corrected: o Y
o N
Pupils:
o Equal
o Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and
again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific
questions on the student's
on the reverse side. * Local district policy may require an annual physical
MEDICAL HISTORY FORM
exam.
NORMAL
ABNORMAL FINDINGS
INITIALS*
Lymph
Heart-Auscultation of the heart
the supine
Heart-Auscultation of the heart
the standing
Heart-Lower extremity
Genitalia (males
Marfan’s stigmata
pectus excavatum,
hypermobility,
MUSCULOSKELETAL
*station-based examination only
CLEARANCE
o Cleared
o Cleared after completing evaluation/rehabilitation for: __________________________________________________________
_________________________________________________________________________________________________________
o Not cleared for:_________________________________________Reason: _________________________________________
Recommendations: _________________________________________________________________________________________
_________________________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of
Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners,
or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.
Name (print/type) __________________________________________ Date of Examination: ______________________________
Address: ___________________________________________________________ Place Office Stamp Here:
Phone Number: _______________________________________________________
Signature: _____________________________________________________
Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.
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