Khsaa Athletic Participation - Physical Examination Form - Consent And Release 2009 Page 2
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4KHSAA Form GE04 Part 1, Physician and Parental Permission, Rev. 4/09, page 2 of 4
Please explain any YES answers from questions 1-31 on page 1. ________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PART III - PHYSICAL EXAMINATION
This part must be completed by the authorized health care provider named in Bylaw 2.
PATIENT NAME: ____________________________________________
HEIGHT: ______ WEIGHT ______ BP _____ / ______ PULSE ______
VISION: R- 20/ ____ L- 20/ ____ BOTH- 20/ ____ CORRECTED? Y N
Normal
Abnormal
Comment
HEART
Rhythm (Regular/Irregular)
Murmur (supine)
Murmur (standing)
ENT
Lungs
Skin
Abdominal
Genitalia
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Dental
Other
After having reviewed the data above and the student's medical history, I make the following recommendations on participation in athletics:
1. Cleared _________________________________________________________________________________________________
2. Cleared after additional evaluation for __________________________________________________________________________
3. Restricted from participating in the sports of ______________________________________________________________________
4. Cleared only to participate in the sports of _______________________________________________________________________
Recommendations/Restriction (attach additional if necessary) ___________________________________________________________
_________________________________________________________________________________________________________
In accordance with KHSAA Bylaws, I have examined the physical condition of the student and find the said student to be physically fit to
practice for and participate in interscholastic athletic contests.
Provider’s Name (please print)
Authorized Signature
Address:
City/State/Zip
Date:
Phone
This Physical Examination is valid for one year from date administered.
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