Confidential Athletic Pre-Participation Physical Examination Form (Page 3 of 3) in pdf

PROVIDER’S PHYSICAL EXAMINATION FORM

Name ____________________________________________________________________

Date of Birth _______________________

Height __________________ Weight ______________

Pulse __________ BP: Left Arm_______/_______ Right Arm _______/_______

Vision R 20/_______ L 20/_______ Corrected: Y N

Pupils: Equal _______ Unequal _______

NORMAL

ABNORMAL FINDINGS

INITIALS*

MEDICAL

Appearance

Eyes/ears/nose/throat

Hearing

Lymph nodes

Heart

Murmurs

Pulses

Lungs

Abdomen

Hernia

Skin

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hands/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

*Multiple examiner set-up only.

Notes: ________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

CLEARANCE

¨ Cleared without restriction

¨ Cleared with recommendations for further evaluation or treatment for:_______________________________________________________________

________________________________________________________________________________________________________________________

¨ Not cleared for

¨ All sports

¨ Certain sports _____________________________________ Reason: ______________________________

Recommendations:_________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Name of physician/medical provider [print or type] ___________________________________________________

Date ____________________

Address _____________________________________________________________________________ Phone _____________________________

Signature of physician/medical provider ______________________________________________________________________________________

PARENT’S OR GUARDIAN’S PERMISSION AND RELEASE

I certify that the information provided by the student/parent(s) is accurate to the best of my knowledge. I hereby give my consent for the above student to

engage in approved athletic activities as a representative of his/her school, except those indicated above by the licensed professional. I also give my

permission for the team physician, athletic trainer, or other qualified personnel to have access to information provided here as well as to give first aid

treatment to this student at an athletic event in case of injury. If emergency service involving medical action or treatment is required and the parents(s) or

guardian(s) cannot be contacted, I hereby consent for the student named above to be given medical care by the doctor or hospital selected by the school.