Athletic Physical Form

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Medical history to be completed by parent (must be completed before physical)
Any past injuries
Presently taking medication
Fainting or dizziness while exercising
History of head injury
Allergies
Significant past illness
Asthma
Orthodontia (braces)
Wears contact lens/glasses
Any ongoing medical problems
Past surgical procedures
Seizures
Any hospitalizations
Bone/joint problems
(Normal)
Comments/Follow-up
General condition
Gastrointestinal
Skin
Lungs
Ears
Genito-urinary
Eyes
Neurological
Nose
Musculoskeletal
Throat
Spinal
Mouth/dental
Nutritional status
Cardiovascular
Mental health
I approve this student's participation in interscholastic sports for one year
Additional comments
PNP Signature
Physician Signature
Date
Tetanus (date)
Comments on any Yes
Parent/Guardian signature
Physical Exam
Height
Weight
Blood pressure
Pulse
Name
Birthdate
Grade
School
Address
Home Phone
Sport(s)
Father
Work phone
Mother
Please give alternatives to contact in case of emergency in the event neither parent can be reached:
Phone
Name
Athletic Physical Form