Doctor's Physical Form
To be completed by Physician and Nurse
NAME: ___________________________________________________________________
HEIGHT ________________WEIGHT______________BLOOD PRESSURE ___________
SIGNIFICANT PAST ILLNESS OR INJURY _____________________________________
___________________________________________________________________________
___________________________________________________________________________
Specific Essentially Abnormal Comments
Examination Normal
____________________________________________________________________________
Head
____________________________________________________________________________
Eyes
____________________________________________________________________________
Ears
____________________________________________________________________________
Neck
____________________________________________________________________________
Chest/Lungs
_____________________________________________________________________________
Heart
_____________________________________________________________________________
Abdomen
_____________________________________________________________________________
Neurological
_____________________________________________________________________________
Hernia Check
______________________________________________________________________________
Muscle/Skeletal
______________________________________________________________________________
Based on medical history and this examination, this student may participate in athletic activities.
__________________without restriction
__________________with restrictions, as follows
______________________________________________________________________________
______________________________________________________________________________
___________________________________ ___________________
Examining Physician Date of Examination
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