Preparticipation Physical Evaluation Form Page 2
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3Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM
Name _______________________________________________________________Date of Birth___________________
Height_________Weight________% Body Fat (optional)________Pulse_______BP____ / ____ (____ / ____, ____/____)
Vision R 20/______ L 20/______
Corrected:
Y
N
Pupils: Equal ______
Unequal______
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary (males only)+
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
*Multiple-examiner set-up only.
+Having a third party present is recommended for the genitourinary examination.
Notes: ____________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of physician (print/type)________________________________________________________________Date______________
Address__________________________________________________________________________Phone____________________
Signature of physician _______________________________________________________________________________, MD or DO
c
2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
Osteopathic Academy of Sports Medicine.
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