Mus Pre-Participation Medical History Form - 2016-2017 Page 2
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8PRE-PARTICIPATION PHYSICAL EXAMINATION
NAME:__________________________________________________
GENERAL PHYSICAL EXAMINATION
EXAM DATE:______/________/________
Height: _____ ft. _____in
Weight: _________
Blood Pressure: _______/______
Pulse: ________
NORMAL
ABNORMAL FINDINGS
Ears, Nose & Throat
Chest, Heart & Lungs
Abdominal, Genitalia
& Hernia
Skin & Lymphatic
MUSCULOSKELETAL
EXAMINATION
NORMAL
ABNORMAL FINDINGS
Cervical Neck and Back
Upper Extremities
Lower Extremities
Flexibility
ADDITIONAL PHYSICIAN NOTES:
_____________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
OFFICIAL RECOMMENDATION:
A. This athlete ____MAY ____MAY NOT compete in athletics based on information obtained from this examination
B. Prior to participation, treatment or follow-up care is recommended for:_________________________________________
_________________________________________________________________________________________________.
C. Recommend further consultation with:___________________________________________________________________
Printed Name of Examining/Clearing Physician:___________________________________________
Signature of Examining/Clearing Physician:_____________________________________________ Date:______/_____/______
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