Lc - Pre-Participation Examination Form Page 2

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PHYSCIAL EXAMINATION
Height _________________ Weight ___________________ Blood Pressure _______________
Pulse: resting _____________ 1 min. exercise_______________ after 1 min. rest___________
_______________________________________________________
Student’s Name
Pulse Ox: Resting___________ 1 min. exercise ______________ after 1 min. rest ___________
Visual Acuity: Eyes (R) 20/ ___________ (L) 20/___________ Corrected: ____Y ____N
Finger-tip span: ___________________________________ BMI:_________________________
Other Testing
Normal
Abnormal Findings
1.
General
______________________________________
2.
Skin
______________________________________
3.
HEENT
______________________________________
4.
Teeth (Dental Exam)
______________________________________
5.
Neck
______________________________________
6.
Lungs
______________________________________
7.
Heart (Sit and Stand)
______________________________________
8.
Abdomen
______________________________________
9.
Genitalia
______________________________________
10. Musculoskeletal
Neck
______________________________________
Shoulder/Arm
______________________________________
Elbow/Forearm
______________________________________
Wrist/Hand
______________________________________
Back
______________________________________
Hip/Thigh
______________________________________
Knee
______________________________________
Shin/Calf
______________________________________
Athletic Physical
Ankle/Leg
______________________________________
Foot
______________________________________
11. Peripheral Pulses
______________________________________
12. Neurologic
______________________________________
13. Mental Status
______________________________________
14. Marfan Screen
______________________________________
Other Tests (optional)
Auditory
UA
EKG
Hgb/Hct
Tanner Stage
% Body Fat
Drug Screen
Chest X-Ray
SMAC
On the basis of the examination on this day, I approve this student’s participation in
interscholastic sports for one year.
Yes
No
Limited
Additional Comments:
____________________________________________
_____________________
Physician/APN/PA Signature
Date
__________________________________________
______________________
Trainer’s Signature
Date

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