Pre‐Participation Physical Exam Sport: ________________________________________________ Date:__________________ Personal Information Name:_________________________________ Date Of Birth:__________________________ SS#: ________________ID#: _______________ Age: ____ Sex: M F Athletic Year: Fresh Soph Campus/Local Address: ___________________ Permanent Address: ____________________ _______________________________________ _____________________________________ Campus/Local Phone: ____________________ Permanent Phone: ____________________ Parent Information Father/Guardian:_______________________ Mother/ Guardian:_______________________ Address: _____________________________ Address: _______________________________ Phone: ______________________________ Phone: ________________________________ SS#: ________________________________ SS#: ___________________________________ Employer: ___________________________ Employer: ______________________________ Employer Address: ____________________ Employer Address: _______________________ ____________________________________ _______________________________________ Employer Phone: _____________________ Employer Phone: _________________________ Health Insurance Information Primary Insurance Company Name: ________________________________________________ Address: ______________________________________________________________________ Phone: _______________________________________________________________________ Policy Number: _____________________ Group #: ___________________________________ Are you covered by Medicare/ Medicaid? YES NO Emergency Information Name: _________________________________________ Phone (Primary):________________ Relationship: _________________________________ Phone ( Secondary):_______________ Family Physician Name and Practice of Family Physician: _____________________________________________________________________________ Address of Family Physician: _____________________________________________________ Phone of Family Physician: ____________________________ Date Last Seen: _____________ I hereby state that to the best of my knowledge, the above information is correct. Athlete’s Signature: ________________________________________ Date: _______________ 1 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Athletic Injuries and Surgeries Have you ever had an athletic injury and/or surgery to the following: Shoulder Y N ______________________________________________________ Hand/Wrist Y N _______________________________________________________ Knee Y N _______________________________________________________ Ankle Y N _______________________________________________________ Feet Y N _______________________________________________________ Back Y N _______________________________________________________ Hips Y N _______________________________________________________ Thighs Y N _______________________________________________________ Abdominal Y N _______________________________________________________ Chest Y N _______________________________________________________ Other Y N _______________________________________________________ Orthopedic Screening Neck AB N ______________________________________________________ Spine AB N ______________________________________________________ Shoulders AB N ______________________________________________________ Arms/Hands/Wrists AB N ______________________________________________________ Hips AB N ______________________________________________________ Thighs AB N ______________________________________________________ Knees AB N ______________________________________________________ Neuromuscular AB N ______________________________________________________ Have you ever been hospitalized or had any other surgeries other than what has been mentioned above? Y N If Yes, Explain: ______________________________________________________________________________
______________________________________________________________________________ Are there any other health related problems or questions you have that you would like to discuss with the athletic trainer or a physician? ______________________________________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ _____________________________ _________________________ Physician’s Signature Physician’s Phone 2 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Vital Signs Height: ______________(in) Weight: ________________(lbs) Pulse: ________________(BPM) Blood Pressure: _________/______________ Vision: _____/_______ Glasses /Contacts /NA Medical ENT AB N _____________________________________________________ Eye AB N _____________________________________________________ Head AB N _____________________________________________________ Lungs AB N _____________________________________________________ Chest AB N _____________________________________________________ Heart AB N _____________________________________________________ Spine AB N _____________________________________________________ Abdomen AB N _____________________________________________________ Hernia AB N _____________________________________________________ Skin AB N _____________________________________________________ Testicular AB N _____________________________________________________ Neurologic AB N _____________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ Comments: ______________________________________________________________________________
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______________________________________________________________________________ ___________________________________ ______________________________ Physician’s Signature Physician’s Phone 3 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Flexibility Screening Optional Section: Spine R L _______________________________________________________ Neck R L _______________________________________________________ Ankle R L _______________________________________________________ Feet R L _______________________________________________________ Knee R L _______________________________________________________ Hip R L _______________________________________________________ Back Test: Squat R L _______________________________________________________ Repetitive: Flexion R L _______________________________________________________ Extension R L _______________________________________________________ Prone Trunk Lift R L _______________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ __________________________ __________________________ Examiner’s Signature Date Athletic Trainer Clearance Participation Recommendations: Pass Fail ______________________________________________________________ __________________________ Athletic Trainer’s Signature __________________________ Date 4 Revised August 2015