Athletic Medical History And Physical Form - The Covenant School Page 2
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2TO BE FILLED OUT BY A PHYSICIAN:
Student Name: _____________________________________________________
Date of Birth: _________________
Height: __________ Weight: __________ Sex: _____
Age: ______ Blood Pressure: ________________________
VISION:
: __________
: __________
: __________
: __________
Right Uncorrected
Right Corrected
Left Uncorrected
Left Corrected
Eyes: _______________
Ears: _______________
Nose: __________________
Throat: _________________
Teeth: _______________
Skin: _______________
Lungs: __________________
Heart: _________________
Abdomen: _______________
Back: _______________
Genitourinary (Hernia): ________________________
Cervical spine/ Neck: _______________
Upper Extremities: _______________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
I have reviewed the medical information above and make the following
recommendations for his/her participation in athletics: (check one)
Full participation in contact and non-contact sports
Requires additional evaluation - Reason: ____________________________________________________________
__________________________________________________________________________________________________
Limited participation - Reason: ____________________________________________________________________
__________________________________________________________________________________________________
No participation - Reason: ________________________________________________________________________
__________________________________________________________________________________________________
Printed Name of Physician:
_____________________________________________________________________________________
Signature of Physician:
______________________________________________________
Date:
_______________________
Questions? Please contact The Covenant School Athletic Office at (434) 220-8108.
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