Inter-Scholastic Team Sports Physical Form
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1Santa Barbara Unified School District
Inter-scholastic Team Sports Physical Form
(C.I.F. Athletic Participation Health Form)
Student Information—to be completed by student (parent signature required at bottom)
Name ______________________________________________________________________________________
Last
First
Address ___________________________________________________________________________________
Street
City
Zip
Phone
History
1. Have you ever had (circle if yes)
allergies
asthma
seizures
heart murmur
a broken bone
diabetes
surgery
admission to a hospital
2. Do you wear corrective lenses during sports? Yes ____ No ____
3. Is your hearing normal?
Yes _____ No _____
4. Do you take medication?
Yes _____ No ______ If yes, what? ___________________________
5. Please note any other medical information that school personnel may need ________________________
____________________________________________________________________________________
Parent Permission for exam ___________________________________________________________________
Parent/Guardian signature
Date
Physician Information—to be completed by physician or nurse practitioner only
Physical Examination
Height _____________ Weight _____________ B.P. _______ / _______ Pulse ___________________
Code:
0=Negative
X=Positive
NE=No Examination
1. Ears, nose, throat
8. Musculoskeletal evaluation
2. Eyes—pupil equal reactive
8.1 Flexibility/stability of joints
symmetry of eye movement
gait
hand
3. Dental—missing teeth
kneebend
chipped teeth
8.2 Spine—scoliosis
removable teeth
8.3 Swelling of any joint
orthodontia
8.4 Muscular weakness
4. Lungs
8.5 Atrophy
5. Heart
thigh
shoulder girdle
6. Abdomen
calf
arm
7. Hernia
9. Incoordination/loss of balance
Additional findings, comments and/or recommendations _____________________________________________
___________________________________________________________________________________________
“I certify that I have on this date examined this student and that, on the basis of the exam requested by the school
authorities and the student’s medical history as furnished to me, I have found no reason which would make it
medically inadvisable for this student to compete in supervised athletic activities.”
If student is not medically fit to participate in athletics or if there are exceptions to the above statement,
examining physician should indicate above.
Signature of Examining Physician ___________________________________ Phone _________________
Print Name __________________________________Date __________ Agency_____________________
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