Physical Examination Form printable pdf download

Name:

DOB:

ATHLETIC PREPARTICIPATION PHYSICAL EVALUATION*

PHYSICAL EXAMINATION FORM

TO EXAMINING HEALTH CARE PROVIDER:

SEND ONLY THE “ATHLETE SUPPLEMENTAL HEALTH FORM”

KEEP THIS FORM WITH YOUR RECORDS – DO NOT SEND THIS FORM TO MIDDLEBURY COLLEGE

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

 Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, myopia, VPS, aortic insufficiency)

Eye/ears/nose/throat

 Pupils equal

 Hearing

Lymph nodes

Heart

 Murmurs (auscultation standing, supine, +/- valsalva)

 Location of point of maximal impulse (PMI)

Pulses

 Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)

Skin

 HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

 Duck-walk, single leg hop

Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam

Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion

Name of Physician (Print)______________________________________________________________________

Address______________________________________________________________________

______________________________________________________________________

Phone__________________________________ Fax________________________________

Date of Exam________________________Date this form completed_________________________

Signature______________________________________________________________________

*Adapted from “Preparticipation Physical Evaluation 4

Edition” as developed by the coalition of American Academy of Family Physicians, American Academy of Pediatrics, American College

of Sports Medicine, American Medical Society of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

Physical Examination Form

Related Articles

Related forms

Related Categories