Athletic Physical Assessment Form
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1Athletic Physical Form
Name:
Age:
Grade:
Date:
Sport(s):
Address:
Home Phone:
Guardian 1:
Work Phone:
Guardian 2:
Work Phone:
Emergency Contact:
Phone No.:
Medical History
Significant Previous Injuries:
No
Yes:
Hospitalizations or Surgeries:
No
Yes:
Bone or Joint Injuries:
No
Yes
Current Medications:
No
Yes:
Past Medications:
No
Yes:
Chronic Illness:
No
Yes:
Allergies:
No
Yes:
Vaccinations are Current:
Yes
No:
Seizures:
No
Yes
Glasses or Contact Lenses:
No
Yes
Asthma:
No
Yes
Fainting/Dizzy Spells:
No
Yes
Physical Exam
Height:
Weight:
Blood Pressure:
Feature
Result
Comments
General
Eyes
Nose
Dental/Mouth
Throat
Ears
Skin
Cardiovascular
Musculoskeletal
Neurological
Genitourinary
Gastrointestinal
Spinal
Nutritional Status
Mental Health
Additional Comments:
I approve this student’s participation in interscholastic sports for one (1) year.
Yes
No
Physician:
Signature:
Date:
PNP:
Signature:
Date
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Parent category: Medical