Mckinney Independent School District Uil Physical Exam Form Page 4
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4PHYSICALS MUST BE COMPLETED AFTER APRIL 1, 2014
PREPARTICIPATION PHYSICAL EVALUATION- PHYSICAL EXAMINATION
Student Name: _________________________________________________________________
Date of Birth_____/______/_______
Last
First
M.I.
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and again prior to first and third years of
high school athletic participation. It must be completed if there are any yes answers to specific questions on the student's Medical History Form. * Local district
policy requires a physical exam per school year not calendar year.
Height____________ Weight______________
%Body fat (optional)_________ Pulse__________ BP___/___(___/____)
Vision R 20/______ L 20/_____
Corrected: Y N
Pupils: Equal___________ Unequal___________
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart-Auscultation of the heart in the supine
position.
Heart-Auscultation of the heart in the standing
position.
Heart-lower extremity pulses
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
Marfan’s stigmata (arachnodactyly, pectus
excavatum, joint hypermobility, scoliosis)
Examining Physician's Signature:_____________________________________________________________________________
*station-based examination only
NORMAL
ABNORMAL FINDINGS
INITIALS*
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Foreman
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
Examining Athletic Trainer's Signature:________________________________________________________________________
*station-based examination only
CLEARANCE Please Check or Circle One:
Cleared
Cleared after evaluations/rehabilitation for________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
NOT CLEARED
FOR:______________________________REASON:_______________________________________________________________
Recommendations:___________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of
Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners,
or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be accepted.
Name (print/type)_____________________________________________Date of Exam____________________________
Address:____________________________________________________________________________________________
Phone Number:_______________________________________________________________________________________
Signature:___________________________________________________________________________________________
Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or games/matches.
PHYSICALS DATED BEFORE APRIL 1, 2014 WILL NOT BE ACCEPTED.
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