Physical Form

Last Updated (Wednesday, 06 January 2010 22:14) Written by Loren Sandhop Attention: open in a new window.

PHYSICAL FORM

Last Name                   First Name        I         Birth Date

Height                                        Weight
Corrected
BP                    Pulse                 Vision (R)          (L)                Uncorrected

GENERAL EXAM                   NORMAL   ABNORMAL

Head, Eyes, Ears, Throat
Lymph glands, thyroid
Heart
Lungs
Abdomen
GU Including hernia, testicles

MUSCULOSKELETAL EXAM           NORMAL   ABNORMAL

Upper Extremity Joints
Upper Extremity ROM, Symmetry
Neck
Spine Motion
Lower Extremity Gait
Lower Extremity Joints
Lower Extremity ROM

Assessment:             Full Participation (Contact)              Limited Contact

Participation Limited: (List Reasons)_______________________________

Circle One                    Medically Cleared      Not Cleared

Doctor’s Signature                              Date

Doctor’s Stamp:

PERSONAL HISTORY (To be filled out by parent or guardian)

__________________________________________________________
Last Name                   First Name           Birthdate

___________________                                      ________
Address                                   School

_____________
Home Phone Number                       Cell Number

Email Address ________________________________________________

Family Doctor/Phone Number
Yes       No

1. Are you under the care of a physician for any specific problem?
If so, what problem?
2. Are you allergic to any medication?   If so, what medication?
3.   Is there a history of Heart disease or murmur?
4.   Is there any PERSONAL history of diabetes, epilepsy, arthritis,
asthma, single kidney, anemia or high blood pressure?
5.   Do you use an inhaler if you have asthma?
6. Have you ever been knocked unconscious?   When?
7. Have you ever had surgery?   If so, list yr. and surgery.
8. Have you ever had Knee, Ankle, Shoulder injury? (Circle)
9. Have you ever had a back injury, neck injury, arm/finger/toe
injury?     (Circle)
10. Have you ever been hospitalized for any illness besides
surgery?     If so list here:

I have filled out the above and certify them to be true to the best of my knowledge.   I realize that this does not substitute for a regular exam performed by my family doctor.   I agree to having my son or daughter examined and to his/her participating in any sport unless otherwise specified here            _______                                     .

Parent/Guardian                                                       Date