Preparticipation History And Physical Examination Form Page 2
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2PHYSICAL EXAMINATION
Optional
Age:____________
Pulse:____________
Urinalysis:
Height:____________
Blood Pressure:____________
Body Fat %
Weight:____________ Visual Acuity: Left 20/_______
HCT:
Right 20/ _______
EST VO2 Max:
Audiometry:
Normal
Abnormal
1.
Head
2.
Eyes (pupils), ENT
3.
Teeth
4.
Chest
5.
Lungs
6.
Heart
7.
Abdomen
8.
Genitalia
9.
Neurologic
10.
Skin
11.
Physical Maturity
12.
Spine, Back
13.
Shoulders, Upper extremities
14.
Lower extremities
Assessment:
Full participation
Limited participation (describe limitations, restrictions):
Participation contraindicated (list reasons):
Recommendations (equipment, taping, rehabilitation, etc.):
DATE: _________________________
EXAMINER’S SIGNATURE: ____________________________
EXAMINER’S PHONE: (
)___________________ PRINT EXAMINER’S NAME: ___________________________
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