Medical Form
To be completed annually by a licensed physican.
(Circle One)
Yes No 1. Has recently (during the last year) had injuries requiring medical attention.
Yes No 2. Is currently under physicans care. If yes, print physicians Name_______________________Phone_____________
Yes No 3. Is taking prescription medication now. Please list:_____________________________________
Yes No 4. Wears glasses, contact lenses, or orthodontic wear.
Yes No 5. Has had surgical operation. Explain.________________________________________________
Yes No 6. Any reason why the student should not participate in sports? If yes, explain.___________________
_____________________________________________________________________________
7. Most recent tetanus toxoid immunization date:___________________________________________
8. List known allergies:__________________________________________________
9. List any chronic diseases (such as asthma or
diabetes):____________________________________
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Examination |
Satisfactory |
Unsatisfactory |
No Exam |
Examination |
Satisfactory |
Unsatisfactory |
No Exam |
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Neurological |
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Skin |
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Musculoskeletal |
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Hearing |
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Blood Pressure |
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Respiratory |
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Cardiovascular |
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Vision |
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Liver, Spleen, Kidney |
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Lab Test(s) |
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Hernia, Genitalia |
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If any of the above are Unsatisfactory or No Exam, please comment:___________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I certify that I have examined this student and find him/her physically able to participate in sports, except_________________________
Physicians Signature________________________________________ Date of Exam______Phone_________________