Medical Form
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Lake Superior State University Athletic Training, Norris Center 650 W. Easterday Ave. Sault Ste. Marie, MI 49783
PRE-PARTICIPATION PHYSICAL EXAMINATION NAME________________________________ DOB ______________ SPORT ________________________________ SSN __________________________ YEAR _____________ HEIGHT _________ WEIGHT ___________ Vision R 20/_____ L 20/_____ Corrected: Y N ̷ Pupils Equal ______ Pupils Unequal ______ Arm span if male >6’ or female >5’10” _______ Pulse _______ BP ____/____ (____/____ ____/____)
NORMAL
ABNORMAL FINDINGS
INITIALS
MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin Hernia Urinalysis Neurologic
MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot ̷ Cleared ̷ Cleared after completing evaluation/rehabilitation for: ____________________________________________________ _________________________________________________________________________________________________ ̷ Not cleared for: ________________________ Reason: __________________________________________________ Name of examiner (Print Name) _______________________________________ Date: ____________ Address __________________________________________________________________________________________ Signature ______________________________________ Phone ___________________________________
PRE-PARTICIPATION PHYSICAL EXAMINATION NAME________________________________ DOB ______________ SPORT ________________________________ SSN __________________________ YEAR _____________ HEIGHT _________ WEIGHT ___________ Vision R 20/_____ L 20/_____ Corrected: Y N ̷ Pupils Equal ______ Pupils Unequal ______ Arm span if male >6’ or female >5’10” _______ Pulse _______ BP ____/____ (____/____ ____/____)
NORMAL
ABNORMAL FINDINGS
INITIALS
MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin Hernia Urinalysis Neurologic
MUSCULOSKELETAL Neck Back Shoulder/Arm Elbow/Forearm Wrist/Hand Hip/Thigh Knee Leg/Ankle Foot ̷ Cleared ̷ Cleared after completing evaluation/rehabilitation for: ____________________________________________________ _________________________________________________________________________________________________ ̷ Not cleared for: ________________________ Reason: __________________________________________________ Name of examiner (Print Name) _______________________________________ Date: ____________ Address __________________________________________________________________________________________ Signature ______________________________________ Phone ___________________________________
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