As a physician, it is important to have a standard physical form that you use when examining your patients. This will help ensure that you are collecting all of the necessary information and that your examination is as thorough as possible. Having a standard physical form also helps to ensure that your documentation is accurate and complete. If you are looking for a standard physical form to use in your practice, be sure to check out the one available on our website. We offer both a printable and an online version, so you can choose the option that best meets your needs.
You can find more info relating to the standard physical form by looking through the table our team put together for you.
Question | Answer |
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Form Name | Standard Physical Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | standard physical form template, blank form physical, standard physical form pdf, printable blank physical form |
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O.K. Conference |
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Medical Examination |
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THIS SIDE TO BE COMPLETED BY EXAMINING MEDICAL PROFESSIONAL |
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Name: |
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Date: |
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Ht:__________ Wt:___________ HR:___________ BP:___________ BP reck:___________ |
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Corrective Lenses: Y or N |
Vision: R________ L________ |
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Physical Exam |
Normal |
Abnormal |
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General Appearance |
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HEENT |
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Lymph Nodes |
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Heart |
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Pulses |
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Lungs |
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Abdomen |
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Skin |
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Neurologic |
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Spine |
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Upper Extremity |
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Lower Extremity |
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Joint Specific (optional) |
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Hernia (males only) |
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COMMENTS |
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General Medical |
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Musculoskeletal |
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RECOMMENDATIONS:
1.[ ] CLEARED WITHOUT RESTRICTIONS
2.[ ] Cleared for LIMITED PARTICIPATION (specify)_______________________________________
_________________________________________________________________________________
3.[ ] NOT CLEARED for participation (explanation) ________________________________________
_________________________________________________________________________________
4.[ ] Requires further evaluation before final recommendation ________________________________
_________________________________________________________________________________
I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activity as dictated by the clearance recommendations above.
Printed Name:______________________________________________ Date:__________________
Signature:_________________________________________________ MD, DO, PA, or NP
A
O.K. Conference
Emergency Information
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School: _____________________ |
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Name:__________________________________ DOB:__________ Gender: M F |
Grade:________ |
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Parent/Legal Guardian Name(s):_______________________________________________________ |
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Address:__________________________________________________________________________ |
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Street |
City |
State |
Zip |
Phone #s: Home:__________________ Work:___________________ Cell:____________________
Emergency Contact(s):
Name:________________________________ Relationship:____________ Phone:_______________
Name:________________________________ Relationship:____________ Phone:_______________
Insurance Information:
Family Insurance Co.:__________________________________________ Phone:_______________
Contract/Group #:___________________________ Policy #:_________________________________
Parent/Legal Guardian Consent & Assumption of Risk:
Participation in interscholastic athletics requires an acceptance of risk of injury. These risks include, but are not limited to the following: death, quadriplegia, paraplegia, internal injury, closed head injury (possibly including
Parent/Legal Guardian Signature:_______________________________________ Date:___________
Authorization of Treatment:
I, ________________________________, hereby give my permission for my son/daughter, ____________________________,
to undergo medical treatment for any injury or illness he/she may sustain or acquire while participating in interscholastic athlet- ics. I understand that medical personnel, including athletic trainers and sideline team physicians, will perform only those proce- dures within their training, credentialing, and scope of professional practice to prevent, care for, and rehabilitate athletic injuries or illnesses. In the event more serious medical treatment/procedures are required and I cannot be reached for my consent, I authorize any licensed medical practitioner to perform such treatments/procedures medically necessary to alleviate the problem.
Parent/Legal Guardian Signature:_______________________________________ Date:___________
A
Medical History |
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1. Do you have any chronic or ongoing medical conditions? |
Yes |
No |
If yes, explain:____________________________________________________________________
2. Have you ever been hospitalized and/or had surgery for any reason?Yes No If yes, explain:____________________________________________________________________
3. Do you have any allergies (medications, insects, foods, etc.)?Yes No If yes, explain:____________________________________________________________________
4. Are you currently taking any medications or supplements (include
5. Have you had a medical problem or injury since your last physical exam?Yes No If yes, explain;____________________________________________________________________
6. Have you ever passed out or nearly passed out during or after exercise? |
Yes |
No |
Have you ever had chest pain, tightness, or pressure during or after exercise? |
Yes |
No |
Have you ever been dizzy or light headed during or after exercise? |
Yes |
No |
Do you get more tired or short of breath than others during exercise? |
Yes |
No |
Does your heart ever race or skip beats (irregular beats) during exercise? |
Yes |
No |
Has a doctor ever ordered a test for your heart (e.g. ECG/EKG, echocardiogram? |
Yes |
No |
Have you ever been told you have any of the following (check all that apply):
High blood pressure |
Heart murmur |
High cholesterol |
A heart infection |
Kawasaki disease |
Other:_____________________ |
Explain ALL yes answers & checked items:_____________________________________________
_______________________________________________________________________________
7. Has anyone in your family died suddenly OR of heart problems before age 50? |
Yes |
No |
Do anyone in your family have a heart problem, pacemaker, or implanted defibrillator? Yes |
No |
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Has anyone in your family had unexplained fainting, seizures, or near drowning? |
Yes |
No |
Does anyone in your family have any of the following cardiovascular conditions:
Hypertrophic cardiomyopathy |
Marfan syndrome |
Brugada syndrome |
Arrythmogenic right ventricular cardiomyopathy |
Long QT syndrome |
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Catecholaminergic polymorphic ventricular tachycardia |
Short QT syndrome |
Explain ALL yes answers & checked items:_____________________________________________
_______________________________________________________________________________
8. Have you ever had a concussion, head injury, or recurrent headaches?Yes No If yes, explain:____________________________________________________________________
Have you ever been knocked out or unconscious?Yes No If yes, explain:____________________________________________________________________
Do you have headaches with exercise?Yes No If yes, explain:____________________________________________________________________
Have you ever had any of the following after a hit, blow to the head, or falling:
Confusion |
Prolonged headache |
Inability to move your arms or legs |
Memory problems Numbness, tingling, or weakness in your arms or legs
Explain ALL checked items (include dates):_____________________________________________
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Have you ever had a stinger, burner, or pinched nerve?Yes No If yes, explain:____________________________________________________________________
Have you ever had seizures, convulsions, or a history of epilepsy?Yes No If yes, explain:____________________________________________________________________
9. Have you ever become ill, dizzy, or passed out while exercising in the heat?Yes No If yes, explain:____________________________________________________________________
Do you get frequent muscle or heat cramps when exercising?Yes No If yes, explain:____________________________________________________________________
Do you or someone in your family have sickle cell trait or disease?Yes No If yes, explain:____________________________________________________________________
10.Do you or someone in your family have asthma or another obstructive lung disorder? Yes No If yes, explain:____________________________________________________________________
Do you cough, wheeze, or have difficulty breathing during or after exercise?Yes No If yes, explain:____________________________________________________________________
Have you ever used an inhaler or taken asthma medication?Yes No If yes, explain:____________________________________________________________________
11.Do you currently have, or have you EVER HAD any of the following:
Hernia Mononucleosis Diabetes Kidney disease Scoliosis Absent spleen Explain ALL checked items (include dates):_____________________________________________
_______________________________________________________________________________
12.Are you missing one of a set of paired organs (kidneys, eyes, ovaries, testes, etc.)? Yes No If yes, explain:____________________________________________________________________
13.Have you ever sprained, strained, dislocated, fractured, broken, experienced repeated swelling in, had a stress fracture in, or otherwise injured any bones or joints? (check all that apply)
Head |
Neck |
Chest/ribs |
Back |
Shoulder |
Forearm |
Elbow Wrist |
Hip |
Thigh |
Calf/shin |
Knee |
Ankle |
Foot/toes |
Hand/fingers |
Explain ALL checked answers (include dates):__________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
14.Have you ever had a condition/injury that required
15.Do you use any special equipment (braces, pads, mouthguards, neck rolls, etc.)? Yes No If yes, explain:____________________________________________________________________
16.Have you had any problems with your vision or injuries to your eyes? |
Yes |
No |
Do you wear glasses, corrective lenses, or protective eyewear? |
Yes |
No |
Explain ALL yes answers:___________________________________________________________
17.Have you ever had any skin problems (rashes, itching, MRSA, herpes, acne)?Yes No If yes, explain:____________________________________________________________________
18.Have you ever had an eating disorder or restricted food to lose weight? |
Yes |
No |
Do you want to weigh MORE or LESS than you do now? |
Yes |
No |
Do you feel stressed? |
Yes |
No |
Explain ALL yes answers:___________________________________________________________
20.FEMALES ONLY Age at 1st menstrual period?___________ Date of most recent?____________
Number of periods in the last 12 months?________ Longest time between periods?__________
21.Has a doctor ever denied or restricted your participation in sports for any reason? Yes No If yes, explain;____________________________________________________________________
**I hereby state that, to the best of my knowledge, the answers to the above questions are complete and correct.
Signature of Athlete:_____________________________________________ Date:_____________
Signature of Parent/Guardian:______________________________________ Date:____________