Physical Exam Form
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1
2IF YOU ARE PLAYING A VARSITY SPORT A PHYSICAL EXAM IS REQUIRED
YOU WILL NOT BE CLEARED TO PARTICIPATE WITHOUT SUBMITTING THIS COMPLETED
FORM TO THE STUDENT HEALTH CENTER FOR REVIEW.
Varsity Sports Physical Examination
MUST BE WITHIN LAST 12 MONTHS, ALL INFORMATION IS REQUIRED AND MUST BE FILLED OUT BY A HEALTH CARE PROVIDER
Name: _________________________________ Student ID:
Date of Birth
__________ ______
___/_____/_
Sport:________________________
*Keep a copy of this form for your records*
Date of Exam_____________________
EXAM: (please address each area below)
Height
Weight
BMI
BP
Pulse
Skin: ____________________________________________________________
Head: ___________________________________________________________
Eyes:
Snellen R/20
L/20_________________________
Corrected R/20
L/20_________________________
Contact lens/glasses: _________________________________
Ears: ___________________________________________
Nose: ___________________________________________
Mouth and Throat: _______________________________
Neck: ____________________________________________
Thorax: _
Lungs: ___________________________________________
Breast: _________________________________________
Lymph Nodes: _____________________________________
Spine/Back: _____________________________________
Extremities: _______________________________________
Genito- urinary (testicles):__________________________
Reflexes: _________________________________________
Heart: __________________________________________
Abdomen: ________________________________________
Laboratory exam: (Optional) HgB / Hematocrit
___ Urine Sugar
Urine Protein______
Cholesterol________
Please answer all following questions:
Does this student have a medical condition for which ongoing health care is required?
Yes
No
If yes, please describe.______________________________________________________________________________
Does this patient use an inhaler prior to exercise?
Yes
No
Is there any evidence of a heart murmur?
Yes
No
If yes, has the murmur been evaluated by Echo?
Yes
No
Has the murmur been determined by workup to be benign and not interfere with activity?
Yes
No
Is there a history of any Heart Disease (arrhythmia, arterial disease, congenital)?__________________
Yes
No
____________________________________________________________________________________
Has this patient had a history of serious head injury/concussion?
Yes
No
If yes, please describe._________________________________________________________________________________
If more than one (1) concussion how many_____ and the date of the last concussion. ______________________________
●
Are there any restrictions or contraindications to athletics?
Yes
No
If yes, please describe__________________________________________________________________________________
Are there any special braces or pads to be worn for sports?
Yes
No
If yes, please describe.______________________________________________________________________________
Recommendations for the physical and mental health care at RPI? _____________________________
Yes
No
Was patient given Sickle Cell Test? (If no, student must sign acknowledgement/declination below)
Yes
No
This patient is in good physical condition and may participate in unlimited physical activity including
contact varsity level sports, non-contact varsity level sports, intramurals and ROTC.
Yes
No
If no, please describe. _______________________________________________________________________________
STUDENT ACKNOWLEDGEMENT – Sickle Cell information sheet (page 2 below/reverse) reviewed and test declined:
______________________________________________________________________________________________
Student signature and date
Signature of the Health Care Provider___________________________________
Health Care Provider’s Name: __________________________________________
Return all information to:
Address: ___________________________________________________________
Student Health Center-RPI
Telephone Number: (
)______-___________
110 8
th
Street- 3200 Academy Hall
Fax Number: (
)______-_________________
Troy, NY 12180
*Stamp may be used, but must be accompanied by signature and date
(518)276-6287 Fax: (518)276-8573
healthrecords@rpi.edu
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