Preparticipation History And Physical Examination Form - Clark County Youth Football Page 2
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2PHYSICAL EXAMINATION
Age:____________
Pulse:____________
CLARK COUNTY YOUTH FOOTBALL
PHSYICAL EXAMINATION FORM.
Height:____________
Blood Pressure:____________
EACH PARTICIPANT IN C.C.Y.F. IS REQUIRED
TO HAVE A PHYSICAL EXAMINATION EACH
CALENDAR YEAR. PHYSICAL EXAMINATIONS ARE
ST
ST
VALID FROM JANUARY 1
THRU DECEMBER 31
.
Weight:____________ Visual Acuity: Left 20/_______
THIS EXAMINATION IS BEING COMPLETED ON
Right 20/ _______
MONTH__________ DAY______ YEAR20____
ST
AND EXPIRES ON 31
OF DECEMBER, THE SAME
CALENDAR YEAR.
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):
DATE: _________________________
EXAMINER’S SIGNATURE: ____________________________
EXAMINER’S PHONE: (
)___________________ PRINT EXAMINER’S NAME: ___________________________
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