Sports Physical Form - Ontario Christian Schools
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1ONTARIO CHRISTIAN SCHOOL – SPORTS PHYSICAL FORM
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Student’s Name _______________________________Grade in September_________ Date of Birth_________
Height____________
Weight____________
Pulse____________
BP___________ / ___________
Vision R 20/________
L 20/________
Corrected: Yes No
Pupils: Equal______
Unequal_______
NORMAL
ABNORMAL FINDINGS
MEDICAL
General Appearance
Nutritional status
Eyes/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
______________________________________________________
Other restrictions (if any) are:
__________________________________________________________________________
_________________________________
Recommendations for additional Medical/Vision/Dental Care:
__________________________________________________________________________
This individual is cleared to participate in any and all sports offered at Ontario Christian School.
YES_____ NO_____
PHYSICIAN’S CLEARANCE TO PARTICIPATE:
In my opinion, he/she is qualified to participate in Ontario Christian School’s athletic program:
_____________________________________
_____________________________________
Print Name of Licensed Physician
Signature of Licensed Physician
_________________________________________________________________________________________
Street
City
Zip
_________________________________________________________________________________________
Telephone
Fax Number
Date
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Parent category: Medical