Preparticipation Physical Examination

 

Name:                                                              Year in school:

Date:                                                               Phone number:                       

Sex:                                                                 Birthdate:

Address:

 

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Height   ____________________________      

Weight  ____________________________

Vision   ____________________________  

Hearing ____________________________

BP         ____________________________ 

Pulse     ____________________________       

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Orthopedic and Doctor Evaluation:

 

Body Part	Normal	Abnormal	Notes
Head, face, scalp
Neck
Upper extremity:      Shoulder      Elbow      Wrist      Hand
Lower extremity:      Hip      Knee      Ankle      Feet
Spine
Abdomen
Ears
Lungs
Heart
Nose and sinuses
Endocrine system
Neurological system

           

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Notes on EKG results:

Notes on Blood work:

 

*Results will be stapled to back of this form

Have you had any of the following health problems? Explain positive answers below

 

	Yes	No
Diabetes
Epilepsy/Seizures
Heart Problems
Lung Disease
Kidney Disease
Chronic Skin Problems
Liver Disease
Hepatitis- Types A, B or C
Drug or alcohol abuse
HIV or AIDS
Hearing Problems
Vision Problems
Back Pain
Psychological Problems
Paralysis
Other Health Problems

 

 

List any allergies you have to medications:

 

 

What medications do you take on a regular basis?