Athletic Physical Examination Form printable pdf download

ATHLETIC PHYSICAL EXAMINATION FORM

Exeter Region Cooperative School District

(Cooperative Middle School and Exeter High School)

Name:__________________________________ Sex:___ Birthdate:

Grade:_________

Address:________________________________________________ Telephone:____________

Sport:_________________________

PAST MEDICAL PROBLEMS

Surgery: _____________________________________________________________________________

Heart Problems or Disease: ______________________________________________________________

Previous Injuries (fractures, dislocation, concussion): _________________________________________

Allergies: ____________________________________________________________________________

Anything Else of Importance: ____________________________________________________________

IMMUNIZATIONS

OPV _________ ________ _______ ________ ________

TD BOOSTER _______

DPT _______ _______ _______ _______ _______

MMR #1 _________ #2 _________

TB – (TINE) ________

RESULTS ________

HEPATITIS B #1 ________ #2 ________

#3 ________

GENERAL INFORMATION

AGE ________ HEIGHT ________ WEIGHT ________ ENT ________

ORTHOPEDIC ________ TEETH _______ BACK _______

HEART ________ HERNIA ________ BLOOD PRESSURE ________

GENERAL CONDITION_____________________________________________________________

PAIRED ORGANS – FUNCTION?

EYES ________ EARS ________ TESTES ________ KIDNEYS ________

ANY MEDICATION AT PRESENT _______________________________________________

PHYSICIAN’S STATEMENT

Please list any and all needed instructions and/or restrictions relating to this student’s participation in

interscholastic athletics. (IF NONE, PLEASE WRITE NONE)

__________________________________________________________________________________

Having examined the above named student, I certify that the medical information on this form is accurate

and I find no contraindications preventing his/her participation in interscholastic athletic activities for the

current school year.

Signature of Licensed Medical Doctor:_________________________ Date of Exam:____________

Address:______________________________________________________________________

Telephone:_____________________

NOTE TO PARENTS AND PHYSICIAN

All students who plan on taking part in interscholastic athletics MUST have a current physical form on file at

their school prior to participation.

In the event of a student suffering a prolonged illness or injury under the care of a physician, a physician must

provide written permission before the student may return to athletic participation.

trainer will

In the even of an injury, when a physician is not responsible for the care of a student, the athletic

determine whether or not that student may participate in athletics.

Athletic Physical Examination Form

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