Physical Evaluation Form (Page 2 of 2) in pdf

Physical Evaluation Form Page 2

Have you ever injured any other joint (shoulder, wrist, fingers, etc)?

Have you ever had a broken bone (fracture)?

Have you ever had a cast, splint, or had to use crutches?

Must you use special equipment for competition (pads, braces, neck roll, etc)?

Has it been more than five (5) years since your last tetanus booster shot?

Are you worried about your weight?

Females: Have you any menstrual problems?

Have you any medical concerns about participating in your activity?

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Student Signature _____________________________________________ Date _________________________

Parent/Guardian Signature______________________________________ Date _________________________

Section B: To Be Completed By Physician

Age ______ Height _________

Weight ________

BP ___________

Pulse ________ Visual Acuity L 20/__ R 20/__

Normal

Abnormal Findings

Initials

Head

Eyes, ENT

Teeth

Chest

Lungs

Heart

Abdomen

Genitalia

Neurologic

Skin

Physical Maturity

Spine, Back

Shoulders, Upper Extremities

Lower Extremities

Assessment:  Full Participation

 Limited Participation (describe limitations, restrictions in box below)

 Participation contraindicated (list reasons in box below)

Recommendation (equipment, taping, rehab, etc):

Date ___________________ Physician’s Signature_____________________________ Print Physician Name ______________________________

August 2009

Physical Evaluation Form Page 2