Physical Examination Form
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PHYSICAL EXAMINATION FORM
(To be completed, signed and dated by your Health Care Provider)
Student Name:_________________________________________________________________D.O.B._______________________
Ht:______________
Wt:_____________
BP:_______________P:_______________ R:___________________
Visual Acuity: OD20/
OS 20/
Last eye exam:_____/_____/_______ Contacts_______ Glasses________
Norm.
Abn.
N.E.
Comments:
Head
Eyes
Teeth
Neck (incl. thyroids)
Chest & Lungs
Heart
Abdomen
Genitalia (incl. hernia)
(Pelvic, if indicated)
Rectal (if indicated)
Spine
Extremities & Joints
Neurologic
Skin
Emotional status
Urinalysis
Are you aware of any other pertinent information pertaining to this student’s health that has not been addressed in the history and physical?
Yes______ No______. If Yes, Please elaborate:____________________________________________________________________
_____________________________________________________________________________________________________________________
THE FOLLOWING IS REQUIRED OF ALL MOUNT ST. MARY’S STUDENTS
PPD
Date Given_____/_____/______ Date Read_____/_____/______ Results: _________mm
(Tuberculin Skin Test)
(Date must be within 1
Chest x-ray (required if TB skin test is positive)
year)
Date of chest x-ray _____/_____/______ Results:________ Normal______Abnormal______
Date of last Td/Tdap Booster (must be within 10 years) _____/_____/______
Date of Meningococcal Vaccine _____/_____/______ Booster Date _____/_____/______
oYES o NO This student is a member of an NCAA athletic team. If YES, complete this shaded section
o This patient is cleared for full participation in NCAA college athletics ________________________
(Provider’s Initials)
o This patient is not cleared for full NCAA participation. The following restrictions are in place:_______________________________
The NCAA requires that all NCAA athletes have documentation of their sickle cell trait status
o This patient has tested (-) for sickle cell trait. (Please attach documentation)
o This patient has tested (+) for sickle cell trait. (Please attach documentation)
o This NCAA Student--Athlete agrees to release a copy of this physical to Mount St. Mary’s Sports Medicine staff.
(Copies of immunization records are not required by the Sports medicine staff)
___________________________________________________
_____________________ _______________________
(Signature of NCAA Student-Athlete)
(Date)
(Sport)
(Provider’s Office Stamp Here)
________________________________________________ _________________
Providers’ Signature
Date
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Parent category: Medical