Athletic Pre-Participation Physical Examination Form - New Jersey Department Of Education Page 3
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4ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM
Part B: Physical Examination
(To be completed by the examining physician)
Examination Date: _________________
-STUDENT INFORMATION-
Student’s Name: __________________________________
Sport: _______________________________________________________
ex: M F (circle one)
Age: ________
S
Grade: _____________
Date of Birth: _________________________________________
Address: _____________________________________________________________________________________________________________
City/State/Zip:________________________________________________
Home Phone: _________________________________________
School: _____________________________________________________
District: _____________________________________________
Parent/Guardian’s Full Name: ____________________________________________________________________________________________
-PHYSICIAN INFORMATION-
Name: _______________________________
Phone: __________________________
Fax: _____________________
Address: ______________________________
City/State/Zip:____________________________________________________
__________________________________________________________________________________________________________
PHYSICIAN OR PROVIDER INFORMATION – PLEASE COMPLETE BOTH PAGES_________________
Height: _________
Weight: _________
Blood Pressure: ______/_______ Pulse: _____bpm.
Vision: R 20/____ L 20/ ____
Corrected: Y / N
Contacts: Y / N
Glasses: Y / N
Indicators
Normal?
Abnormal Findings/Comments
(Circle One)
Head/Neck
YES
NO
Eyes/Sclera/Pupils
YES
NO
Ears
YES
NO
YES
NO
Nose/Mouth/Throat
Heart:
YES
NO
Murmurs/Rhythms
Lungs:
Auscultation/Percussion
YES
NO
Chest Contour
YES
NO
Skin
YES
NO
Abdomen:
Assessment (incl. liver, spleen)
YES
NO
Tanner Stage:
Testes/Onset of Menses:
YES
NO
Neck/Back/Spine:
YES
NO
Range of Motion:
YES
NO
Scoliosis:
YES
NO
Upper Extremities:
YES
NO
Lower Extremities:
YES
NO
Neurological:
Balance & Coordination:
YES
NO
Romberg:
YES
NO
Heel Walk:
YES
NO
YES
NO
Tandem Walk:
Nose Touch:
YES
NO
Toe Walk:
YES
NO
Hernia?
YES/
NO
(if yes/possible, please explain)
Possible
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