College Physical Exam Form
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1PLEASE USE THIS FORM AND COMPLETE ALL QUESTIONS
BATES COLLEGE PHYSICAL EXAM FORM
To the examining physician: Please review the student’s health history form and complete this physical examination form. We
ask that you comment on all abnormalities. Examinations by physician parents or other relatives will not be accepted. All blanks must be
filled in – including physician’s signature & date. Failure to complete physical as requested will result in non clearance for sports
participation No Exceptions. Please return to: The Health Center, Bates College, Lewiston, Me 04240 or fax to: (207)-786-8240.
NCAA rule states physicals must be within 6 months of participation.
Last Name: ____________________________________First:____________________M.I.______
Date of Birth: ____________________Class:______________________Male __ Female __
Home Phone # :______________________________Bates/cell #:______________________
_____________________________________________________________
List all Sports at Bates:
Clinical Evaluation
D.O.B. ____________ Height_________________
Weight ______________
Blood Pressure ________
Pulse____________
Normal/No
Abnormal/Yes
(Please Explain)
1. EENT (Include thyroid)……………………………………..
________________________________________
2. Chest and Lungs (Include Breasts)………………………….
________________________________________
*3. Heart (history of exercise-induced problems)
Ex. fainting, irregular rate?..........................................
________________________________________
*4. Heart Murmur (Any cardiac abnormality requires full
cardiac evaluation, echocardiogram and records)…….
_________________________________________
5. GI (hernia, etc.)…………………………………….………..
_________________________________________
6. Endocrine system…………………………………….………
_________________________________________
7. Orthopedics…………………………………………………..
_________________________________________
8. Current Orthopedic problems..………………………………
_________________________________________
(Include surgeries within past nine months)
_________________________________________
9. Neurologic…………………………………………………...
_________________________________________
10. Concussions? …………………….......................................
Number of_____Dates__________LOC?________
_________________________________________
11. Genito Urinary (males include testicles)…………………..
_________________________________________
12. Is this student under treatment for any medical issues?.......
_________________________________________
13. Is this student under treatment for any psychological
issues?.......................................................................................
_________________________________________
14. Any medication or therapy?.please list ................................
_________________________________________
Athletes on medication for ADD or ADHD must have Sports Medicine form completed by physician.
Download form here:
15. Are there any dietary restrictions?.........................................
_________________________________________
16. History of eating disorders/concerns?...................................
_________________________________________
*17. Are there any restrictions on physical activity?................
_________________________________________
*18. Are there any sports this student is unable to
participate in?........................................................................
_________________________________________
19. Allergies……………………………………………………
_________________________________________
20. Sickle Cell Trait All Athletes must have lab work. Documentation required. Send results to Bates Health Center.
*FOR ALL SPORTS PHYSICALS: Please write on the back of this form pertinent health history including major
illnesses, hospitalizations, surgeries, traumatic head injuries, orthopedic injuries, and cardiac problems. For serious injuries
or illnesses within the past year, please include any restrictions and a note of clearance to play sports. (First year students
playing sports – please use separate sheet if needed.)
___________________________________________________________________________________________
DATE
Signature of physician
Address
Telephone (include area code)
______________________________________________________________________________________________________
Release of Information
I_____________________hereby authorize the Bates College Health Center and Bates Sports Medicine to communicate
medical information, obtained in the course of treatment for injury or illness which is relevant to my participation in athletic
activities, including the Physical Exam form.
Student Signature_____________________________________Date_________________
First Year Students Only: Please complete immunization information on the other side
3/13
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