Preparticipation Physical Evaluation – Warren High School

VALID FOR SCHOOL YEAR:

STUDENT ID: _____________________

2017/2018

Preparticipation Physical Evaluation – Warren High School Date of Exam ____________________________

PHYSICAL EXAMINATION

Name ___________________________________________________________________ Sex ______ Age ______ Date of Birth ____________ LAST NAME

FIRST NAME

Height ______________ Weight _______________ % Body fat (Optional) __________ Pulse ____________ BP ____________/____________ Vision R 20/ ____________ L 20/ ___________ Corrected: MEDICAL Appearance

Yes

No

Pupils Equal ___________ Unequal _____________

NORMAL

ABNORMAL FINDINGS

INITIALS*

NORMAL

ABNORMAL FINDINGS

INITIALS*

Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (Males Only) Skin MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand Hip (thigh) Knee Leg/ankle Foot *Station-based examination only

CLEARANCE  

Cleared Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________



Not Cleared for: ________________________________________________________ Reason: ______________________________________________

Recommendations:_________________________________________________________________________________________________________________

Name of Approved Medical Provider (print/type/stamp) _____________________________________________________________ Date __________________ Address ____________________________________________________________________________________________ Phone _______________________

Office Stamp _________________________________________________________________, M.D, D.O., PA-C, RNP (ONLY) SIGNATURE OF APPROVED MEDICAL PROVIDER ONLY