To the Health Care Provider: Please complete ALL portions of this examination form! All information is mandatory. An answer of N/A to
any of the following will not be acceptable. Your examination and recommendations are the basis for this student’s medical care and will be
used to determine if it is safe for this student to participate in varsity athletics at the University of the South in Sewanee, Tennessee. If
the student wishes to play varsity football, the NCAA mandates that all physical examinations must be administered by a physician and
only a physician. A physician's assistant, nurse practitioner , or chiropractor is not acceptable. This information is strictly for the use
of the Athletic Department and will not be released without the student’s consent.
Name of Student______________________________________________
Date of Exam____________________________________________
Height_________________ Weight__________________ ___
B/P__________________
Medication Allergies__________________________________
Daily Medications________________________________________________
Normal
Pulse__________________________________
Abnormal
1. Eyes
2. Ears, Nose, Throat
3. Head and Neck
4. Cardiovascular
5. Chest and Lungs
6. Abdomen
7. Genitalia / Hernia
8. Orthopedic Screening
a. neck
b. spine
c. shoulders
d. arms and hands
e. hips
f. knees
g. legs and feet
Comments
Corrective Lenses?
Date of last pap (if applicable)
Taking into consideration the student’s history (see health history form) and physical examination, is there any reason to prohibit / limit
participation in varsity sports at the University of the South? If yes, please explain:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Are their any specific recommendations regarding the student’s general medical care (specific monitoring, follow-up, etc.)?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
If there is a history of eating disorders, cardiac problems, or attention deficit disorders, a current status report from the treating physician and/or
therapist is required.
Health Care Provider’s Signature
Address
Name (Print)
Degree
Office Phone Number
Name: ____________________________________
Date: _________
Sport: ____________
Circle one: FR/SO/JR/SR
HEALTH HISTORY FORM
(To be completed by student and parents prior to examination)
1. Has this student ever had:
a. Hospitalizations?
b. Surgery?
c. Chronic illnesses?
d. Emotional problems (depression, eating disorders)
e. Problems related to alcohol or drug use?
f. Missing organs? (i.e. eye, kidney, testicle)
g. Blood pressure problems?
h. Heart problems?
i. Chest pain with exercise?
j. Dizziness or fainting with exercise?
k. Concussions?
(See page 3)
l. Head, neck, or spine injury?
m. Heat exhaustion or heat stroke?
n. Asthma or exercise-induced asthma?
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2. Does the student:
a. Take medication everyday?
b. Wear glasses or contact lenses?
c. Wear dental appliance or hearing aids?
d. Have special dietary requirements?
e. Receive allergy shots?
f. Wear orthotics? If yes, for what condition?
g. Require any special services?
YES NO
Explain if Yes
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3. Is the student currently taking prescribed medicine for
ADHD, ADD, or any other learning disability?
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Answering YES requires additional documentation. See ADHD Documentation Letter
4. Has the student or anyone in the student’s family been
diagnosed with or treated for sickle cell trait?
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5. Has the student's mother, father, brothers or sisters
ever had any heart problems before 50 years of age?
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6. Has any physician ever limited the student's
athletic participation?
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7. If female, have periods been absent for more than three
consecutive months?
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Name: ____________________________________
Date: _________
Sport: ____________
Circle one: FR/SO/JR/SR
HEALTH HISTORY FORM (continued)
8. Is there any history of musculo-skeletal injury?
a. Neck injuries?
(muscle sprain, ligament strain, whiplash
pinched nerve, ruptured disk, fracture, etc)
Yes
No
___ ___
If yes, please explain
________________________
________________________
________________________
b. Shoulder injuries?
(Strain, tendonitis, bursitis, AC Sprain,
separated shoulder, rotator cuff injury,
separation, dislocation, etc)
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________________________
________________________
________________________
c. Elbow injuries?
(UCL sprain, muscle strain,
dislocation, tendonitis, etc)
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d. Wrist injuries?
(Ligament sprain, tendonitis, etc)
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e. Hands or fingers?
(fractures, dislocations, sprains, etc)
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f. Back?
(muscle strain, ligament sprain,
pinched nerve, slipped disk, ruptured disk,
stress fracture, spondylolysis, spondylolthesis, etc)
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g. Hip / Groin?
(muscle strain, ligament sprain, labrum injury, etc)
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h. Knee?
(ACL, PCL, MCL, LCL, meniscus or cartilage injury,
tendonitis, osgood schlatter's, chondramalacia,
subluxation, dislocation, etc)
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i. Ankle / shin?
(Sprain, strain, tendonitis, fracture, dislocation, etc)
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j. Foot or toes?
(ligament sprain, morton's neuroma, fracture, etc)
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k. Muscle strains?
(Hamstrings, quadriceps, calf, back, etc)
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Name: ____________________________________
Date: _________
Sport: ____________
Circle one: FR/SO/JR/SR
HEALTH HISTORY FORM (continued)
9. Concussion History
a. Number of times diagnosed with a concussion:
__________________
b. Total number of concussions that resulted in loss of consciousness.
__________________
c. Total number of concussions that resulted in confusion.
__________________
d. Total number of concussions that resulted in difficulty with memory for events occurring
immediately after injury.
__________________
e. Total number of concussions that resulted in difficulty with memory for events occurring immediately before
injury.
___________________
f. Total games were missed as a direct result of all concussions combined. _________________
g. Please list all previous concussions. Please provide the month and the year, at a minimum.
Month
Date
Year
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10. Has the student had any of the following: Yes No
a. Hay fever
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n. Frequent Diarrhea
b. Asthma
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o. Hemorrhoids
c. High blood pressure
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p. Hernia
d. Low blood pressure
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q. Kidney Infection / Stones
e. Frequent headaches
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f. Migraine headache
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g. Frequent sore throats
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t. Diabetes
h. Hearing problem
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u. Epileptic Attacks
i. Heart Trouble
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v. Pneumonia
j. Heart Murmur
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w. Frequent skin infections
k. Ulcer
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x. Frequent colds
l. Nervous Stomach
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y. Hepatitis
m. Appendicitis
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z. Infectious mono
Yes
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No
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If you answered yes to any of the above, please explain: _________________________________________
Being a participant in Intercollegiate Athletics at the University of the South, I authorize the University
Wellness Center, Southern Tennessee Regional Medical Center @ Sewanee (formerly Emerald - Hodgson
Hospital), or any other medical doctor or medical institution which might render medical treatment to me
during this period, to release said records to the team physicians, Athletic Training Staff, Director of Athletics,
and all insurance companies ( a result of participation, and although rare, this injury may include permanent
disability, paralysis, or death. I have answered all of the above questions completely, truthfully, and to the best
of my knowledge. I also understand that I must carry medical insurance for intercollegiate athletics and this
coverage will be primary with the University of the South's policy being secondary only.
SIGNATURE ________________________________
DATE ______________________
GUARDIAN _________________________________
(sign if under 18)
DATE ______________________