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Athletic Physical Form Example

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Text in this example:

Medical history to be completed by parent (must be completed before physical) Yes No Yes No 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 (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 YES NO Additional comments PNP Signature Physician Signature Date 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 Work phone Please give alternatives to contact in case of emergency in the event neither parent can be reached: Name Phone Name Phone Athletic Physical Form

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