Physical Examination Form

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PHYSICAL EXAMINATION FORM
This form must be completed and signed by a HEALTH CARE PROVIDER (physician, nurse
practitioner, or physician assistant), NOT a family member, within one year prior to the first day of
classes.
STUDENT NAME:
STUDENT ID:
AGE:
DATE OF BIRTH:
ALLERGIES:
HEIGHT:
WEIGHT:
R.R.
UNCORRECTED VISION
L 20/
R 20/
TEMPERATURE:
B.P.
PULSE
CORRECTED VISION
L 20/
R 20/
O.U. 20/
Do you plan to participate in NCAA Intercollegiate Athletics at University of La Verne?
YES
NO
If so, what sport? _____________________________________________________
Subjective
Objective
Normal
Abnormal
Description
Skin/Body marks
Eyes
Ears
Nose
Mouth, teeth, and
throat
Neck
Chest/Lungs
Heart
Endocrine
Abdomen
Extremities
Hip/Pelvis/Spine
Neurological
Assessment
Plan
Recommendations for intramural/Intercollegiate physical activity
Without restrictions
Should not participate in sports
May participate with the following restrictions:_________________________________________
Medical or orthopedic problem must be evaluated before participation is allowed
Medical provider signature:________________________________________________M.D. / N.P. / P.A.
Medical provider’s printed name:__________________________________________________________
Physician’s address:___________________________________________________________________
Phone: ____________________________
Date of Examination: ____________________
Please return to: Student Health Services

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