PHYSICAL EXAM
(Required every 2
years)
Student______________________________________________ Date___________________
Height__________Weight__________Blood Pressure__________
Eyes R 20/__________ L 20/__________
Ears R__________/15 L __________/15
Respiratory
__________ Cardiovascular __________ Liver__________ Spleen__________
Hernia
__________ Musculoskeletal ___________ Skin
__________ Genitalia __________
Neurological
____________________
Laboratory: Urinalysis (as
needed)________________
Other_______________________________________________________________________
Comments by
physician_________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Recommendations: I feel this young person can participate in
the sport(s) of choice based upon the physical exam I conducted, providing
he/she can pass the physical fitness requirements set forth by the coach and
school in regard to the sport(s).
_________________ ____________________________________________________
Date Signature
of Physician