SPORTS PHYSICAL EXAMINATION

NAME: _______________________________________ SCHOOL: CATHOLIC CENTRAL HIGH SCHOOL
Date of Birth: ____________		Grade: ________				Weight: __________			Height: ________
*Is there a history of:
Heart Disease:			Dislocations:				Lung Disease ___________
Congenital ______________			Knee __________				Kidney Disease ___________
Acquired ______________			Other joints __________				Hernia __________
							Blood dyscrasia (bleeder) __________
Allergy: Antibiotics ______________			Fractures: Complicated __________				Fainting/ Convulsions __________
Pollen ______________			Uncomplicated __________				Epilepsy __________
Drugs ______________
Asthma ______________			Operations __________				Medications __________
			Hospitalizations __________				Injuries __________
Name of Sport	__________________			__________________				__________________
Date of Exam:	__________________ Fall			__________________ Winter				__________________ Spring
*Physical Examination (N=Normal) (P=Pathology)
Tetanus diphtheria pertussis (date) ______________ Heart ____________________________________ Eyes R ________________ L ______________ Ears R ________________ L ______________ Lungs _________________________________ Genital _________________________________ Skin _________________________________ Lymph nodes _______________________________ Tanner stage I II III IV V (circle one)					Scoliosis				_________________
					Blood Pressure-systolic				_________________
					-diastolic				_________________
					Heart Rate				_________________
					Hernia				_________________
					Orthopedic				_________________
					Extremities				_________________
					Abnormalities				_________________
					Abdomen				_________________

Indicate any known congenital defects ____________________________________________

____________________________________________________________________________________________________________________________________________________________

Dental: List any dental abnormalities _____________________________________________

*IF SUSPECTED PATHOLOGY EXISTS, FURTHER CONSULTATION AND WORK-UP REQUIRED.

The above examination shows satisfactory condition to engage in:

______________________________________________________________________________

______________________________________	_______________________________________
Signature of Private Physician/date	Signature of School Physician/date
THIS FORM IS TO BE RETAINED IN SCHOOL’S CUMULATIVE HEALTH RECORD FILE.

FOR SCHOOL PHYSICIAN USE ONLY

This certifies that _____________________________ is physically qualified to
participate in the following categories of competition during the school year 20____ to
20____.

Any unmarked categories indicate disqualification from the particular group of sports
activities.

CONTACT/COLLISION LIMITED CONTACT/ STRENUOUS NONSTRENUOUS

IMPACT NONCONTACT NONCONTACT

Field Hockey Baseball Tennis Archery

Football Basketball Cross-country Bowling

Ice Hockey Diving Track and Field Golf

Lacrosse Gymnastics Swimming

Soccer Handball

Wrestling Skiing-Cross Country

Skiing-Downhill

Softball

Volleyball

________________________________________

School Physician’s Signature

________________________________________

Date