Form Tma/tssaa - Preparticipation Medical Evaluation (Page 2 of 2) in pdf

Form Tma/tssaa - Preparticipation Medical Evaluation Page 2

TMA/TSSAA PREPARTICIPATION MEDICAL EVALUATION FORM

Page 2 of 2

General Physical Education

Examiner:

Student Name:

Height _______________ Weight ______________ BP __________/__________ Pulse__________

Vision R 20/_____ L 20/_____ Corrected? _____ Yes _____ No Pupils __________

Normal

Abnormal Findings

Ears, Nose, Throat

Heart

Chest/Lungs

Skin/Lymphatic

Abdominal

Genitalia/Hernia

Musculoskeletal Examination

Examiner:

Normal

Abnormal Findings

Neck/Back

Upper Extremities

Lower Extremities

Flexibility

Optional Lab

Urine Sugar __________

Urine Protein _________

Urine Hematest _______

Official Recommendation

A. This athlete _____ may _____ may not compete in athletics based on the data gathered from this exam.

B. Prior to participation, treatment or follow-up on the following in recommended:

C. Recommend further consultation with _______________________________________________________

Signature of Physician: ____________________________________________________ Date: ____________

Form Tma/tssaa - Preparticipation Medical Evaluation Page 2