Ossaa Physical Examination And Parental Consent Form

Ossaa Physical Examination And Parental Consent Form - 2015 Page 2

PREPARTICIPATION PHYSICAL EVALUATION

PLEASE PRINT

DATE OF EXAM ______________________________

Name __________________________________________________________ Date of Birth_______________________________________

Height _______ Weight _______ Body fat (optional) _____% Pulse_______ BP _______/_______ Color Blind Yes

(circle one)

Vision: R 20/_______ L 20/________

Corrected Y / N

Pupils: Equal ______ Unequal ______

MEDICAL

Normal

Abnormal Findings

Appearance

Eyes/Ears/Throat

Lymph Nodes

Heart

Pulses

Lungs

Abdomen

Genitalia (male only)

Skin

MUSCULOSKELETAL

Neck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hand

Hip/Thigh

Knee

Leg/Ankle

Foot

CLEARANCE

( ) Cleared

( ) Cleared after completing evaluation/rehabilitation for:_________________________________________________________________

_______________________________________________________________________________________________________________

( ) Not cleared for: _________________ Reason: ___________________________________________________________

____________________________________________________________________________________________________

Recommendations: ____________________________________________________________________________________

____________________________________________________________________________________________________

Name & Title of Examiner (Print/Type) _____________________________________ Date __________________________

Address _____________________________________________________________ Phone __________________________

Signature of Examiner _______________________________________________________

Ossaa Physical Examination And Parental Consent Form - 2015 Page 2