Physical Examination Form (Page 2 of 2) in pdf

Please comment on whether further evaluation or care is needed: _______________________________________

___________________________________________________________________________________________

I hereby certify that each examination listed above was performed by myself or an individual under my direct

supervision with the following conclusion(s):

Recommendations for Physical Activity: Exercise programs & use of fitness equipment.

Unlimited □ Limited □

Intercollegiate & Recreational Sports: Is this applicant capable of participating in a full program of college study,

including participation in intercollegiate sports/intramural or club sports?

Yes □

No □

□ Cleared after completing evaluation/rehabilitation for: _______________________________________________

Recommendations: ___________________________________________________________________________

Practitioner’s Signature: ______________________________________________ Date:_______________

Please print name & address: _______________________________________________________________

_______________________________________________________________

Telephone: _____________________________________________________

Return original to:

UNH Health Services

4 Pettee Brook Lane

Durham, NH 03824

Telephone: (603) 862-9355

If participating in Division I Intercollegiate Sports, please mail a copy of the physical assessment form to:

UNH Athletic Training

145 Main St., Field House

Durham, NH 03824

If participating in Club Sports, please mail a copy of the physical assessment form to:

Sport Club Coordinator

128 Main St., Hamel Center

Durham, NH 03824

STUDENT: I give consent for this form to be copied and released to the Athletic or Club Sports Department upon

request. (Please complete in case permission is needed at a later date.)

Signature: ________________________________________________________ Date: ____________

Page 2 of 2

Physical Examination Form Page 2