Sports Physical Form (Page 2 of 2) in pdf

Sports Physical Form Page 2

PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN

Height __________

Weight __________

Pulse __________

Blood Pressure __________

Vision: R _____ / _____ uncorrected R _____ / _____ corrected

L _____ / _____ uncorrected L _____ / _____ corrected

Normal

Abnormal Findings

Initials

1. Eyes

2. Ears, Nose, Throat

3. Mouth & Teeth

4. Neck

5. Cardiovascular

6. Chest & Lungs

7. Abdomen

8. Skin

9. Genitalia-Hernia (male)

10. Muskuloskeletal: ROM, strength, etc.

a. neck

b. spine

c. shoulders

d. arms/ hands

e. hips

f. thighs

g. knees

h. ankles

i. feet

11. Neuromuscular

Please Print/ Stamp

Physician’s Name ___________________________________________________________________________________

Street Address _____________________________________________________________________________________

City, State, Zip Code ________________________________________________________________________________

Telephone _________________________________________________________________________________________

I certify that I have examined this athlete and found him/her medically qualified to participate in sports. I also certify that

I am a licensed medical physician, physician’s assistant, or family nurse practitioner. (Doctor of Chiropractic Medicine is

not satisfactory.)

Physician Signature __________________________________________________________ Date __________________

PARTICIPATION RESTRICTIONS: _________________________________________________________________

__________________________________________________________________________________________________

Sports Physical Form Page 2