Pike Area Youth Athletic League PO Box 424 ... - League Athletics
Pike Area Youth Athletic League P.O. Box 424 Milford, PA 18337 845-637-4448 www.payalfootball.org *NOTE: This form MUST BE submitted to the league NO LATER THAN the first day of practice. No child will be allowed to participate without a current physical.
School Year: ______________
Activity:
Football
Cheerleading
Participant Name: (Last) _____________________________________, (First) ____________________________ Height: _________________ Weight: _________________ BP: (rest) ____________ / (post 2 min exercise) ______________ Pulse: (rest) __________ / (post 2 min exercise) ______________ Significant HX: _____________________________________________________________________________________ ………………………………………………………………………………………………………………………………………………………………………………………….. I. PHYSICAL 1. ENT Anisocoria, Braces 2. Heart/Lungs 3. Abdomen 4. Genitals 5. Skin 6. Other II. ORTHOPEDIC SCREENING A. Posture Evaluation Front view: AC Joints, Habitus Back view: Scoliosis/Kyphosis Side view: Lordosis B. Range of Motion/Flexibility Neck Trunk Shoulders Elbows Forearms Wrist/Hands Hamstrings/Adductors Heel Cords Quadriceps Knees Ankles
Normal ________ ________ ________ ________ ________ ________
Abnormal ________ ________ ________ ________ ________ ________
Comments ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
Normal ________ ________ ________
Abnormal ________ ________ ________
Comments ______________________________________ ______________________________________ ______________________________________
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
III. General Review ______ This child MAY participate in the above mentioned activity. ______ This child MAY NOT participate in the above mentioned activity because ____________________________ ______________________________________________________________________________________________ Additional Comments: ______________________________________________________________________________ _________________________________________________________________________________________________ Physician’s Signature: __________________________________________
Date: __________________________
School Year: ______________
Activity:
Football
Cheerleading
Participant Name: (Last) _____________________________________, (First) ____________________________ Height: _________________ Weight: _________________ BP: (rest) ____________ / (post 2 min exercise) ______________ Pulse: (rest) __________ / (post 2 min exercise) ______________ Significant HX: _____________________________________________________________________________________ ………………………………………………………………………………………………………………………………………………………………………………………….. I. PHYSICAL 1. ENT Anisocoria, Braces 2. Heart/Lungs 3. Abdomen 4. Genitals 5. Skin 6. Other II. ORTHOPEDIC SCREENING A. Posture Evaluation Front view: AC Joints, Habitus Back view: Scoliosis/Kyphosis Side view: Lordosis B. Range of Motion/Flexibility Neck Trunk Shoulders Elbows Forearms Wrist/Hands Hamstrings/Adductors Heel Cords Quadriceps Knees Ankles
Normal ________ ________ ________ ________ ________ ________
Abnormal ________ ________ ________ ________ ________ ________
Comments ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
Normal ________ ________ ________
Abnormal ________ ________ ________
Comments ______________________________________ ______________________________________ ______________________________________
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
III. General Review ______ This child MAY participate in the above mentioned activity. ______ This child MAY NOT participate in the above mentioned activity because ____________________________ ______________________________________________________________________________________________ Additional Comments: ______________________________________________________________________________ _________________________________________________________________________________________________ Physician’s Signature: __________________________________________
Date: __________________________
