Athletic Participation/parental Consent/physical Examination Form Page 3
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4Revised March 2013
Page 3 of 4
PART III – PHYSICAL EXAMINATION
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(Physical examination form is required each school year dated after May 1 of the preceding school year and is good through June 30
of the current school year)**
NAME_____________________________________ Date of Birth ______________ School ________________________________
Date of EXAMINATION:
Height
Weight
Male
Female
BP
/
Resting Pulse
Vision R 20/
L 20/
Corrected
Yes
No
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
Eyes/ears/nose/throat
Lymph nodes
Heart
Pulses
Lungs
Abdomen
Genitourinary (males only)
Skin
Neurologic
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
Medical Practitioner to School Staff (please indicate any instructions or recommendations here)
Emergency medications required on-site
Inhaler
Epinephrine
Glucagon
Other:
Comments:
I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for his/her participation in athletics.
CLEARED WITHOUT RESTRICTIONS
CLEARED WITH FOLLOWING NOTATION: _____________________________________________________
____________________________________
Cleared AFTER documented further evaluation or treatment for:
_______________________________________________________________________________
Cleared for Limited participation (check and explain “reason” for all that apply):
“Limited Until Date” when appropriate
Not cleared for (specific sports)________________________________________________Until Date:_________
______________________________________________________________________
Reason(s):
___________________________________________
NOT CLEARED FOR PARTICIPATION Reason
By this signature, I attest that I have examined the above student and completed this pre-participation physical including a review of Part II – Medical History.
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Physician Signature: ______________________________________________________(
MD, DO, LNP, PA) . Date** ___________________
Circle one
Examiner’s Name and degree (print): _______________________________________________Phone Number __________________________
Address: ____________________________________ City _________________________ State _________ Zip _____________________
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Only signatures of Doctor of Medicine, Doctor of Osteopathic Medicine, Nurse Practitioner or Physician’s Assistant licensed to
practice in the United States will be accepted
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