Physical Form - Mt. Lebanon School District

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MT. LEBANON SCHOOL DISTRICT
Physical Form may be used for Pennsylvania Mandates and Sports Exams
Rev. 7-26-12
Please attach copy of Immunization Record and Section 5 (Health History)
SECTION 6: PIAA COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION
AND CERTIFICATION OF AUTHORIZED MEDICAL EXAMINER
Must be completed and signed by the Authorized Medical Examiner (AME) performing the herein named student’s comprehensive
initial pre- participation physical evaluation (CIPPE) and turned in to the Principal, or the Principal’s designee, of the student's school.
Student’s Name
Birth Date
Age
Grade
Enrolled in _______________________________________ School
Sport(s)
Height_______ Weight______ % Body Fat (optional) ______ Brachial Artery BP_____/_____ (_____/_____ , _____/_____) RP
If either the brachial artery blood pressure (BP) or resting pulse (RP) is above the following levels, further evaluation by the student’s primary care
physician is recommended. Age 10-12: BP:>126/82, RP: >104; Age 13-15:BP: >136/86, RP>100; Age 16-25: BP: >142/92, RP>96
Vision R 20/_____ L 20/_____
Corrected
YES
NO (circle one)
Pupils: Equal_____ Unequal_____
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
Eyes/Ears/Nose/Throat
Hearing
Lymph Nodes
Cardiovascular
Heart murmur
Femoral pulses to exclude aortic coarctation
Physical stigmata of Marfan syndrome
Cardiopulmonary
Lungs
Abdomen
Genitourinary (males only)
Neurological
Skin
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
I hereby certify that I have reviewed the HEALTH HISTORY, performed a comprehensive initial pre-participation physical evaluation of the herein named
student, and, on the basis of such evaluation and the student’s HEALTH HISTORY, certify that, except as specified below, the student is physically fit to
participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in the sport(s) consented to by the student’s parent/guardian in Section 2
of the PIAA Comprehensive Initial Pre- Participation Physical Evaluation form:
CLEARED
CLEARED, with recommendation(s) for further evaluation or treatment for:
NOT CLEARED for the following types of sports (please check those that apply):
C
C
N
-
S
M
S
N
-
OLLISION
ONTACT
ON
CONTACT
TRENUOUS
ODERATELY
TRENUOUS
ON
STRENUOUS
Due to
Recommendation(s)/Referral(s)
AME’s Name (print/type)
License #
Address______________________________________________________________________ Phone ( )
AME’s Signature_____________________________
ate of CIPPE (exam)___/____/___
MD, DO, PAC, CRNP, or SNP (circle one)
D

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