Liberty Sports Medicine Pre-Participation Physical Evaluation Health Questionnaire Page 2

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Liberty University
Pre-Participation Physical Evaluation
PHYSICAL EXAMINATION
Name __________________________________________
________
Date of birth ___________________
___________________
Height ____________ Weight ____________ % Body fat (optional) ____________ Pulse ________ BP _____/_____ (_____/_____, _____/_____)
Vision R 20/_____ L 20/_____
Corrected: Y N
Pupils: Equal _____ Unequal _____
NORMAL
ABNORMAL FINDINGS
Initials*
MEDICAL
Appearance
Eye/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia (males only)
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand
Hip/thigh
Knee
Leg/ankle
Foot
*station-based examination only
CLEARANCE
O
Cleared
O
Cleared after completing evaluation/rehabilitation for: ___________________________________________________________________
__
__________________________________________________________________________________________________________________
__
O
Not cleared for: _________________________________________________ Reason: ________________________________________
__
Recommendations: __________________________________________________________________________________________________
__
__________________________________________________________________________________________________________________
__
__________________________________________________________________________________________________________________
__
__________________________________________________________________________________________________________________
__
__________________________________________________________________________________________________________________
__
Name of physician (print/type) _________________________________________________________ Date ___________________________
__
Address ___________________________________________________________________________________________________________
__
Signature of physician _______________________________________________________________________________, MD

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