Farmington Public Schools Sports Physical Exam Form

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FARMINGTON PUBLIC SCHOOLS
SPORTS PHYSICAL EXAM FORM
NAME: _____________________________ Birth Date: ____________ Date of Exam: _______________
th
th
This form may be used in lieu of the state form for the required 6
and 10
grade physical exams. NOTE:
Items with an asterisk (*) indicate mandated screenings under Connecticut State Law for these exams.
A physical exam is valid for one year for interscholastic athletics. If the exam expires during a sports season,
a new one is required before a student may continue participation in practice or play.
Screening/Test Results
NOTE: *Mandated Screening/Test under CT State Law
*Height:
*Postural:
RECENT IMMUNIZATIONS (Td, Hep. B, etc)
___________________________
Normal
Immunization
Date
*Weight:
Abnormal
___________________________
*B/P:
Min._______________
___________________________
Pulse:
Slight ______________
___________________________
TB and Other Test Results (Sickle Cell, etc.)
*HCT/HGB:
Mod. _______________
TB: In high-risk group?
Yes
No
___________________________
Urinalysis:
Marked _____________
Test
Date
Results
___________________________
*Gross dental
Referral
:
___________________________________________________
*Vision/Type of Screening
*Auditory/Type of Screening
*Chronic Disease Assessment:
________________________________________________________________
Date of onset
With
R
L
Pass/Fail
Yes No
glasses
20/
20/
R
Asthma:
mild
moderate
severe
Without
R
L
exercise induced
unclassified
_________
glasses
20/
20/
L
Diabetes:
Type I
Type II
_________
Anaphylactic Reaction:
food
insect
latex _________
Seizure Disorder
_________
Normal
Abnormal Findings
Other: Please specify ______________________
_________
General
Appearance
Normal
Abnormal Findings
Skin
Abdomen
Heent
Spine
Respiratory
Neurological
Cardiovascular
Genitalia (Hernia)
Arrhythmia
Extremities
Murmur
Physical Maturity (Tanner Stage)
1
2
4
5
Comments:________________________________________________________________________________________
_________________________________________________________________________________________________
This student may participate fully in the school program, including physical education activities and competitive sports.
This student may participate in the school program and physical education with the following restriction/adaptation.
(Specify reason and restriction) __________________________________________________________________.
Signature of health care provider
Name (please type or print)
Phone Number
Revised: 6/03

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