Athletics Physical Form - Aylett Country Day School Page 3
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3AYLETT COUNTRY DAY SCHOOL
PHYSICAL EXAMINATION
(Physical examination is required each school year)
NAME____________________________________________________________________ Date of Birth
EXAMINATION
Height:
Weight:
Male
Female
BP :
/
Pulse:
Vision: R 20/
L 20/
Corrected
Yes
No
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
Eyes/ears/nose/throat
Lymph nodes
Heart
Pulses
Lungs
Abdomen
Genitourinary (males only)
Skin
Neurologic
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
Medical Practitioner to School Staff (please indicate any instructions or recommendations here)
Emergency medications required on-site
Inhaler
Epinephrine
Glucagon
Other:
Comments:
I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for his/her
participation in athletics.
CLEARED WITHOUT RESTRICTIONS
CLEARED WITH FOLLOWING NOTATION:
Cleared AFTER documented further evaluation or treatment for:
Cleared for limited participation (check and explain "reason" for all that apply): "Limited Until Date" when appropriate
Not cleared for (specific sports)_________________________________________ Until Date:
Reason(s):
NOT CLEARED FOR PARTICIPATION
Reason(s):
I have examined the above-named student and completed the preparticipation physical evaluation.
+
Physician Signature:
(MD, DO, LNP, PA)
Date
Circle one
Address: ____________________________________________________________________ Phone Number
+ Only signatures of Doctor of Medicine, Doctor of Osteopathic Medicine, Nurse Practitioner or Physician's Assistant licensed to practice in the United States
will be accepted
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