Sports Physical Form - Peace Evangelical Lutheran Church And School
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1Peace Lutheran School
9415 Merriman Road
Livonia, Michigan 48150
(734) 422-6930
Sports Physical Examination Form
(Please Print) Last Name
First Name
MI
Grade______ Birthdate _________________Age ______ Weight ______ Bl. Pressure _______
Significant Past Illness or Injury ____________________________________________________
Eyes: ______________; R20/ ___________; L20/__________; Ears ______________________
Hearing: R _____________________________/15; L ________________________/15
Respiratory: _________________________; Cardiovascular: ___________________________
Liver: ______________________________; Spleen: __________________________________
Hernia: ____________________; Musculoskeletal: ____________________________________
Skin: ______________________; Genitalia: _________________________________________
Neurological: ________________; Laboratory: Urinalysis (As Needed) _____________________
Other: _________________ Comments: ____________________________________________
I certify that I have on this date examined this pupil and find him/her physically able to compete in
supervised activities (Not crossed out):
BASKETBALL
GYMNASTICS
FLOOR HOCKEY
SOCCER
TRACK
VOLLEYBALL
CHEERLEADING
Do you know of any reason why this individual should not participate in all sports?
yes
no
If "yes" please explain: __________________________________________________________
Allergies to medication? _________________________________________________________
Date of exam
(Signature of examining physician)
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