Physical Examination Form
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1RESET FORM
• PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name _____________________________________________________________________________________ Date of birth ________________________________________
PHYSICIAN REMINDERS
1.
Consider additional questions on more sensitive issues
Do you feel stressed out or under a lot of pressure?
Do you ever feel sad, hopeless, depressed, or anxious?
Do you feel safe at your home or residence?
Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
During the past 30 days, did you use chewing tobacco, snuff, or dip?
Do you drink alcohol or use any other drugs?
Have you ever taken anabolic steroids or used any other performance supplement?
Have you ever taken any supplements to help you gain or lose weight or improve your performance?
Do you wear a seat belt, use a helmet, and use condoms?
2.
Consider reviewing questions on cardiovascular symptoms (questions 5-14).
EXAMINATION
Height _____________________ Weight ____________________
_____ Male _____ Female
BP __________ / __________
( _______ / _______)
Pulse _____
Vision R 20 / _____
L 20 / _____
Corrected _____ Yes _____ No
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
•
Marfan s gmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachno-
dactyly, arm span > height, hyperlaxity, myopia, MVP, aor c insufficiency)
Eyes/ears/nose/throat
•
Pupils equal
•
Hearing
Lymph nodes
Heart *
•
Murmurs (ausculta on standing, supine, +/- Valsalva)
•
Loca on of point of maximal impulse (PMI)
Pulses
•
Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)
Skin
•
HSV, lesions sugges ve of MRSA, nea corporis
Neurologic *
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Func onal
•
Duck-walk, single leg hop
*
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
* Consider GU exam if in private setting. Having third party present is recommended.
* Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
_____ Cleared for all sports without restriction
_____ Cleared for all sports without restric on with recommenda ons for further evalua on or treatment for ______________________________________________________________
_____ Not cleared
_____ Pending further evalua on
_____ For any sports
_____ For certain sports __________________________________________________________________________________________________________________________
Reason ________________________________________________________________________________________________________________________________________
Recommenda ons ________________________________________________________________________________________________________________________________________
I have examined the above-named student and completed the prepar cipa on physical evalua on. The athlete does not present apparent clinical contraindica ons to prac ce and
par cipate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of parents. If condi ons
arise a er the athlete has been cleared for par cipa on, the physician may rescind the clearance un l the problem is resolved and the poten al consequences are completely ex-
plained to the athlete (and parents/guardians).
Name of physician (print/type) _______________________________________________________________________________________________Date __________________________
Address ____________________________________________________________________________________________________ Phone _______________________________________
Signature of physician _____________________________________________________________________________________________________________________________MD or DD
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