Physical Examination For Athletes - Hawaii State Department Of Education
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1
2Hawaii State Department of Education
PHYSICAL EXAMINATION FOR ATHLETES
Student’s Name
M/F
Date of Birth______/______/______ Grade
(Print)
Last
First
MI
Month
Day
Year
Address___________________________________ Home Phone_____________ Student Resides With ____________
Street No.
City
State
Zip Code
Fall Sport ____________________
Winter Sport ____________________
Spring Sport
Father’s/Guardian’s Name
Bus. Phone
Cell or Pager____________
Mother’s/Guardian’s Name
Bus. Phone
Cell or Pager____________
Emergency Contact
Bus. Phone
Cell or Pager____________
Name & Relationship
Health and/or Insurance Carrier ________________________
Policy # ___________________________________
To be completed by Physician only
Height _________ feet & inches
Weight ______lbs
Blood Pressure______/______ Pulse______ bpm
Vision: R 20/______ L 20/ ______ Corrected: Yes No Pupils: Equal ____ Unequal ____
Asthma _________
Diabetes ____________
Allergies _________________
(Medication Used)
(Medication Used)
(Medication Used)
MEDICAL
NORMAL
COMMENTS
INITIALS
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart/Murmurs
Pulses
Lungs
Abdomen
Skin
Genitalia
MUSCULOSKELETAL
Neck
Back/Spine
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Calf/ankle
Foot/toes
Other
Clearance:
A. Cleared for all sports __________________
B. Cleared after completing evaluation/rehabilitation for
C. Not cleared for:
Collision
Contact
Non contact
Strenuous
Moderately Strenuous
Non-strenuous
Due to
Physician’s Recommendation
Name of Physician
Date of Physical Exam
Address
Telephone
Signature of Physician
Fax Number
(Over)
RS 06-1385 (Rev. of RS 03-0094)
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Parent category: Medical