Sports Physical Examination

The Master’s School

SPORTS PHYSICAL EXAMINATION

Name: ______Birth Date: ______Mo. Day Yr. Grade: ______

Height: ______Weight:______Blood Pressure: ______Pulse: ______

GENERAL EXAM ORTHOPEDIC EXAM (Musculoskeletal: ROM; Strength: Flexibility)

NORMAL ABNORMAL NORMAL ABNORMAL APPEARANCE NECK SKIN SPINE EENT SHOULDERS RESPIRATORY ARMS/HANDS CARDIOVASCULAR HIPS ABDOMEN THIGH SPINE KNEES NEUROLOGICAL ANKLES GENITALIA FEET

RECOMMENDATIONS FOR SPORTS PARTICIPATION COMMENTS

A. UNLIMITED ______

B. LIMITED TO SPECIFIC SPORTS ______

C. DEFERRED UNTIL ______Date

This student is physically qualified to participate in all contact and non-contact sports. YES____ NO____

Physician’s Signature:______Date of examination:______

Physician’s Name:______

HCT HGB ______Date:______TETANUS BOOSTER ______Date:______MMR BOOSTER ______Date:______VARICELLA ______Date:______HEPATITIS B ______Date:______TB TEST ______Date:______OTHER IMMUNIZATION ______Date:______SPORTS PHYSICAL EXAMINATION

Student’s Name______Age______

1. Has anyone in your family (grandparent, mother, father, Yes No Specific sister, brother, aunt, uncle) died suddenly before age 60? Information

2. Have you ever passed out during exercise or stopped exercising because of dizziness?

3. Do you have asthma (wheezing), hay fever or coughing spells after exercise?

4. Have you ever broken a bone, had to wear a cast or had an injury to any joint?

5. Do you have any history of concussion (being knocked out)?

6. Have you ever suffered from a heat-related illness?

7. Do you take any medication? If so, indicate:

8. Are you allergic to medicine; insect bites; food? Please indicate:

9. Do you have only one of any paired organs (eyes, Ears, kidneys, testicles, ovaries, etc.)? Indicate:

10. Have you ever been hospitalized for medical or Surgical reasons? If so, indicate:

11. Do you have a chronic illness or see a physician for any particular problem? Check those applicable:

Hepatitis ______High Blood Pressure______

Disabilities ______Mononucleosis (year) ______

Diabetes______Epilepsy (Seizures)______

Bleeding Disorder ______Sickle Cell Anemia ______

Other ______

Signature of Student ______Date______