Sports Physical Form Physical Examination Form For Students Name*UID#GradeSchool Site Birth Date MM slash DD slash YYYY SexFatherMotherAddressParent ConsentDate MM slash DD slash YYYY Medical history include:rheumatic fever,tuberculosis,epilepsy,allergies,operations,serious illness,congential defects and menstrual distrubances.Has your son/daughter had a concussion? Yes No If so,how many?Date of Last Concussion: MM slash DD slash YYYY Immunization Recommendations:Physical ExaminationCheckAdditional RemarksNormal,Abnormal,Not ExaminedN A NEGeneral Weight & Nutrition Additional RemarksGeneral Apperance Additional RemarksSkin(Acne,Tinea,Dermatitis) Additional RemarksEye(Conjunctivae,Corena,EOM) Additional RemarksEars(Perforations,Deafness) Additional RemarksNose(Allergy,Deformities) Additional RemarksTeeth(Cavities,Gingivitis,Occlusion) Additional RemarksTonsils Additional RemarksLymph Nodes Additional RemarksChest(Deformities) Additional RemarksLungs Additional RemarksHeart(Size,Murmur,Rhythm) Additional RemarksBreast Additional RemarksAbdomen Additional RemarksHernias Additional RemarksGenitalia Additional RemarksBack(Kyphosis,Lordosis,Scoliosis) Additional RemarksSkelton(Limited Motion,Deformities) Additional RemarksFeet(Flat,Pronated,Tinea) Additional RemarksBlood PressureHeightWeightThis student may praticepate in:Competitive Sports Yes No Regular Physical Education Yes No Limited P.E Only Yes No DurationPhysician's SignatureDate MM slash DD slash YYYY Type or Print Physician's NameLicense NumberPHYSICALS FROM A CHIROPRACTOR ARE NOT VALID FOR ATHLETIC CLEARANCE
