Physical Examination Form printable pdf download

PHYSICAL EXAM

(To be completed by a physician or a nurse practitioner/physicians assistant)

Name: ______________________________ Date:________ Age: ________ Date of Birth: ____________

Preferred Name:____________________________________ Preferred Pronoun: ________________________

Address: ______________________________________________ State: __________ Zip: ____________

Height: _____________ Vision: R: _______/_______ corrected □ / uncorrected □

Yes □

No □

Glasses?

corrected □ / uncorrected □ Contacts? Yes □ No □

Weight: ___________

L: _______/_______

Pulse: ____________ Blood Pressure _______/________

Hearing: ____________

Normal

Abnormal

Comments

Eyes, Ears, Nose, Throat,

Mouth & Teeth

Neck, Thyroid

Cardiovascular

Chest & Lungs

Abdomen

Skin

Genitalia-Hernia

Testicular Exam

Musculoskeletal: ROM, strength, etc.

neck □ shoulders □ arms □

hands □ back □ hips □

knees □ feet □ legs □

Neurological

Date of last gynecological exam:

Pap smear date & result:

Breast Exam

BELOW IS MANDATORY ONLY FOR INTERCOLLEGIATE ATHLETES – MUST BE COMPLETED

SICKLE CELL TRAIT: Positive _____________ Negative _____________ Unknown Status _________

( must be screened or sign waiver)

*Attach lab result of sickle cell trait screening (if available) or signed UNH Sickle Cell Waiver form

*The NCAA encourages ALL Intercollegiate athletes to be aware of their sickle cell trait status

*Waiver form available at:



Does this applicant use tobacco products (cigarettes, cigars, chew, snuff or electronic cigarettes)? Yes □

No □

If yes, have you discussed the risk? Yes □ No □



Has education about the use of alcohol, steroids, dietary supplements and other drugs, including misuse/abuse

of prescription medication, been offered to this applicant? Yes □

No □



Yes □

No □

Have you discussed safer sex issues with this applicant?

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Physical Examination Form

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