Health History Form Page 3
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5MEDICAL/ORTHO PHYSICAL EXAM FORM
Must be completed for ALL student athletes. Individuals who report as having a chronic
condition (marked with *) must also provide a copy of a recent physical.
Comments
R-N R-AB L-N L-AB
Head
Name:_____________________________________________
Spine/ Thorax
S.S. Number _______________________________________
Cervical
Height:___________
Weight:____________
Thoracic
B/P:______/_______
Pulse:______________
Lumbar
N
AB
Comments
Chest/Ribs
Head/Face
Shoulder
Eyes
ROM
Sternoclavicular
Acuity
Clavicle
Movements
Acromioclavicular
Fields
Scapula
Nystagmus
Glenohumeral
Pupils
Upper Arm
Ears
Elbow
Nose
ROM
M. Epicondyle
Mouth / Throat
L. Epicondyle
Tonsils
Radial Head
Neck
Forearm
Nodes
Wrist
Thyroid
Hand and Fingers
Respiratory
Thumb
Upper
Pelvis
Sacroiliac
Lower
Pubis
Cardiovascular
Hip Joint
Rhythm
Thigh
Sounds
Quadriceps
Murmurs
Hamstring
Pulse
Femur
Abdomen
Knee
ROM
Genitourinary
Effusion
Testicles
Lachman
Hernia
Valgus Stress
If Indicated Rectal
Varus Stress
Skin
McMurray Test
Neurological Sx
Patella
Concussion Hx
Lower Leg
Tibia and Fibula
Based on the preceding evaluation, this athlete is:
Achilles Tendon
Ankle
□
Cleared for athletics WITHOUT medical restrictions
ROM
□
Cleared with the following medical restrictions
Med/Lat Malleolus
________________________________________________
Ant. Drawer
□
DENIED clearance due to
Foot
________________________________________________
Midfoot
Med. Long Arch
Toes
Great Toe/ Sesamoid
Evaluating Physician ( print )
Other Toes
Evaluating Physician ( sign and date )
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