Medical Form

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 ___________________________________