Preparticipation History And Physical Examination Form Page 2
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1
2PHYSICAL EXAMINATION
Optional
Age:____________
Pulse:____________
Urinalysis:
Height:____________
Blood Pressure:____________
Body Fat %
Weight:____________ Visual Acuity: Left 20/_______
HCT:
Right 20/ _______
Wrestling
EST VO2 Max:
Minimum Weight Recommended circled below:
High School Weight Classification: 103 112 119 125 130 135 140
Audiometry:
145 152 160 171 189 215 275 (must be over 189)
Junior High School Weight Classification: 80 86 92 98 104 110 115
120 125 130 137 144 152 160 168 180 210 240 270
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):
Student has been checked for concussions and/or head injuries (any findings/recommendations are listed)
Participation contraindicated (list reasons):
Recommendations (equipment, taping, rehabilitation, etc.):
DATE: _________________________
EXAMINER’S SIGNATURE: ____________________________
EXAMINER’S PHONE: (
)___________________ PRINT EXAMINER’S NAME: ___________________________
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Parent category: Medical