Physical Examination Form printable pdf download

Physical Examination Form

South Carolina Independent School Association

Physical Examination Form

Please Print

_____________________________________________________

__________________________

Last Name

First Name

Middle Initial

Date of Birth

Gender: ___ M ___ F

Age: _______

Grade: ________

PHYSICAL EXAM -

To Be Completed By Physician or trained medical personnel under the supervision of a physician.

Height ___________ Weight ___________

Pulse ___________

Blood Pressure ___________

Medical

Normal

Abnormal Findings

Initials

1. Eyes (vision)

2. Ears, Nose, Throat

3. Mouth & Teeth

4. Neck / Lymph Nodes

5. Cardiovascular

6. Abdomen

7. Chest & Lungs

8. Skin

9. Genitalia-Hernia (male)

10. Heart (

squatting to standing &

supine)

Musculoskeletal:

ROM, strength, etc.



Neck



Spine/Back



Shoulders/Arm



Elbow/Forearm



Wrist/Hand



Hip/Thighs



Knees



Leg/Ankles

____ Cleared without restriction

____ Cleared, with recommendations for further evaluation or treatment for: __________________

_____________________________________________________________________________________

____ Not Cleared:

___ All Sports

____ Certain Sports: _________________________________

I certify that I have examined this athlete on this date and found him/her medically qualified to participate

in sports. I also certify that I am a licensed physician or work directly with a licensed physician.

Physician’s Signature: _______________________________________

Date: ____________________

Physician’s Address: ___________________________________________________________________

Physical Examination Form

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