Madison Schools Preparticipation Health Evaluation Page 2
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2PHYSICAL EXAMINATION
Name _______________________________________________________ Date of Birth _________________
To be completed by athlete/parent prior to physical:
HISTORY
YES
NO
HISTORY
YES
NO
HISTORY
YES
NO
Have you ever had:
Have you ever had:
Do you now have:
Fainting
Kidney Disease
Painful Joints____________________
Diphtheria
Tuberculosis
Backaches______________________
Scarlet Fever
Jaundice
Pounding of Heart________________
Rheumatism
Sickle-Cell Anemia
Shortness of Breath_______________
Rupture
Frequent Urination_______________
Rheumatic Fever
Cough_________________________
Do you now have:
Poliomyelitis
Blurred Vision
Nosebleeds______________________
Pneumonia
Headaches
Frequent Sore Throats_____________
Asthma
Fainting
Stomach Pains___________________
Diabetes
Convulsions
_________________________________________________
Heart Disease
Blackouts___________________________________________________________
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To be completed by examining MD, DO, Physician’s Assistant on day of physical:
Height ________________ Weight ________________ Pulse __________ Blood Pressure _____________
Vision: Left ______________
Right _______________
Glasses/Contacts _____________________
PHYSICAL EXAMINATION
To be completed by the examining MD, DO, Physician’s Assistant or Nurse Practitioner.
(Categories may be added or deleted; check appropriate column.)
SYSTEM
NORMAL
ABN.
SYSTEM
NORMAL
ABN________________
Urinalysis
Chest____________________________________________________
Vision
Lungs____________________________________________________
Ears
Heart____________________________________________________
Nose
Abdomen_________________________________________________
Throat
Hernia___________________________________________________
Teeth-Cavities
Genitalia/Testicular Exam____________________________________
Orthopedic
Neurologic________________________________________________
Thyroid
Muscular_________________________________________________
RECOMMENDATIONS: _____________________________________________________________________________
_________________________________________________________________________________________________
I certify that I have examined the above student and recommend him/her as being able to compete in supervised
athletic activities not crossed out below.
BASEBALL—BASKETBALL—BOWLING---COMPETITIVE CHEER—CROSS COUNTRY—FOOTBALL
GOLF—SOFTBALL—TRACK—VOLLEYBALL—WRESTLING
SIGNATURE OF
CIRCLE ONE:
EXAMINER: X
__ MD __ DO __ PA __ NP___________________
PRINTED NAME
DATE:
OF EXAMINER:_________________________________________________________
______________________________________________
A CURRENT YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR.
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Parent category: Medical