Tssaa Preparticipation Evaluation Physical Examination Form
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1TSSAA Preparticipation Evaluation
931.381.BONE (2663) | 800.552.BONE (2663) | FAX 931.380.0513
Physical Examination Form
1050 N. James Campbell Blvd., Suite 200 | Columbia, TN 38401
Name
Date of Birth
Height
Weight
% Body Fat (OPT)
Pulse
BP
/
(
/ ,
/
)
Vision R 20/
L 20/
Corrected
Yes
No
Pupils
Equal
Unequal
❑
❑
❑
❑
Medical
Normal
Abnormal Findings
Initials*
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary (males only)**
Musculoskeletal
Neck
Back
Shoulder/arm
Elbows/forearm
Wrist/hand/ ngers
Hip/thigh
Knee
Leg/ankle
Foot/toes
*Multiple-examiner set-up only. **Having a third party present is recommended for the genitourinary examination.
Cleared without restriction
Cleared with recommendations for further evaluation or treatment for:
❑
❑
Not cleared for
All sports
Certain sports
Reason:
❑
❑
Recommendations
Emergency Information
Allergies
Other Information
Notes
Name of Physician (print/type)
Date
Address
Phone
Signature of Physician
MD or DO
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Parent category: Medical