<p> The Master’s School</p><p>SPORTS PHYSICAL EXAMINATION</p><p>Name: ______Birth Date: ______Mo. Day Yr. Grade: ______</p><p>Height: ______Weight:______Blood Pressure: ______Pulse: ______</p><p>GENERAL EXAM ORTHOPEDIC EXAM (Musculoskeletal: ROM; Strength: Flexibility)</p><p>NORMAL ABNORMAL NORMAL ABNORMAL APPEARANCE NECK SKIN SPINE EENT SHOULDERS RESPIRATORY ARMS/HANDS CARDIOVASCULAR HIPS ABDOMEN THIGH SPINE KNEES NEUROLOGICAL ANKLES GENITALIA FEET</p><p>RECOMMENDATIONS FOR SPORTS PARTICIPATION COMMENTS</p><p>A. UNLIMITED ______</p><p>B. LIMITED TO SPECIFIC SPORTS ______</p><p>C. DEFERRED UNTIL ______Date</p><p>This student is physically qualified to participate in all contact and non-contact sports. YES____ NO____</p><p>Physician’s Signature:______Date of examination:______</p><p>Physician’s Name:______</p><p>HCT HGB ______Date:______TETANUS BOOSTER ______Date:______MMR BOOSTER ______Date:______VARICELLA ______Date:______HEPATITIS B ______Date:______TB TEST ______Date:______OTHER IMMUNIZATION ______Date:______SPORTS PHYSICAL EXAMINATION</p><p>Student’s Name______Age______</p><p>1. Has anyone in your family (grandparent, mother, father, Yes No Specific sister, brother, aunt, uncle) died suddenly before age 60? Information</p><p>2. Have you ever passed out during exercise or stopped exercising because of dizziness?</p><p>3. Do you have asthma (wheezing), hay fever or coughing spells after exercise?</p><p>4. Have you ever broken a bone, had to wear a cast or had an injury to any joint?</p><p>5. Do you have any history of concussion (being knocked out)?</p><p>6. Have you ever suffered from a heat-related illness?</p><p>7. Do you take any medication? If so, indicate:</p><p>8. Are you allergic to medicine; insect bites; food? Please indicate:</p><p>9. Do you have only one of any paired organs (eyes, Ears, kidneys, testicles, ovaries, etc.)? Indicate:</p><p>10. Have you ever been hospitalized for medical or Surgical reasons? If so, indicate:</p><p>11. Do you have a chronic illness or see a physician for any particular problem? Check those applicable:</p><p>Hepatitis ______High Blood Pressure______</p><p>Disabilities ______Mononucleosis (year) ______</p><p>Diabetes______Epilepsy (Seizures)______</p><p>Bleeding Disorder ______Sickle Cell Anemia ______</p><p>Other ______</p><p>Signature of Student ______Date______</p>