This completed form must be kept on ile by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physi- cian, licensed physician assistant or certiied advanced registered nurse practitioner).
Student’s Name: _____________________________________________________________________________________________ Date of Birth: _____/_____/_____
Height: _____________ Weight: _____________ % Body Fat (optional): ____________ Pulse: _________ Blood Pressure: ____ / ____ ( ____/____ , ____ /____ )
Temperature: _____________ Hearing: right: P ______ F _____ left: P _____ F _____ |
|
Visual Acuity: Right 20/_______ |
Left 20/_______ |
Corrected: Yes |
No |
Pupils: Equal _________ Unequal _________ |
|
FINDINGS |
NORMAL |
|
|
ABNORMAL FINDINGS |
INITIALS* |
MEDICAL |
|
|
|
|
|
1. |
Appearance |
________ |
________________________________________________________________________ |
____________ |
2. |
Eyes/Ears/Nose/Throat |
________ |
________________________________________________________________________ |
____________ |
3. |
Lymph Nodes |
________ |
________________________________________________________________________ |
____________ |
4. |
Heart |
________ |
________________________________________________________________________ |
____________ |
5. |
Pulses |
________ |
________________________________________________________________________ |
____________ |
6. |
Lungs |
________ |
________________________________________________________________________ |
____________ |
7. |
Abdomen |
________ |
________________________________________________________________________ |
____________ |
8. |
Genitalia (males only) |
________ |
________________________________________________________________________ |
____________ |
9. |
Skin |
________ |
________________________________________________________________________ |
____________ |
MUSCULOSKELETAL |
|
|
|
|
|
10. |
Neck |
________ |
________________________________________________________________________ |
____________ |
11. |
Back |
________ |
________________________________________________________________________ |
____________ |
12. |
Shoulder/Arm |
________ |
________________________________________________________________________ |
____________ |
13. |
Elbow/Forearm |
________ |
________________________________________________________________________ |
____________ |
14. |
Wrist/Hand |
________ |
________________________________________________________________________ |
____________ |
15. |
Hip/Thigh |
________ |
________________________________________________________________________ |
____________ |
16. |
Knee |
________ |
________________________________________________________________________ |
____________ |
17. |
Leg/Ankle |
________ |
________________________________________________________________________ |
____________ |
18. |
Foot |
________ |
________________________________________________________________________ |
____________ |
* – station-based examination only
ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Precautions: ________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________
_______________________________________________________________________________________________________________________________________
____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________
____ Referred to ______________________________________________________________________________ For: ______________________________________
_______________________________________________________________________________________________________________________________________
Recommendations: _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Name of Physician/Physician Assistant/Nurse Practitioner (print): __________________________________________________________ Date: _____/_____/_______
Address: _______________________________________________________________________________________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner: ____________________________________________________________________________________
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