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Pre-Participation Physical Evaluation

(PRINT OR TYPE) PHYSICIANS STAMP: 1997 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine *Station-based examination onlyPre- participation Physical Evaluation (This page to be completed by physician/nurse practitioner/physician assistant) Physical EXAMINATIONDATE OF EXAM _____NAME _____DATE OF BIRTH _____HEIGHT _____ WEIGHT _____ % BODY FAT (optional) _____ PULSE _____ BP _____VISION R 20/ _____ L 20/ _____ CORRECTED? Y _____ N _____ PUPILS: EQUAL _____ UNEQUAL _____NORMALABNORMAL FINDINGINITIALS *MEDICALA ppearance _____Eyes/Ears/Nose/Throat _____Lymph nodes _____Heart _____Pulses _____Lungs _____Abdomen _____Genitalia (males only) _____Skin _____MUSCULOSKELETALNeck _____Back _____Shoulder/Arm _____Elbow/Forearm _____Wrist/Hand _____Hip/Thigh _____Knee _____Leg/Ankle _____Foot _____CLEARANCEqClearedqCleared after completing Evaluation /rehabilitation for: _____qNot cleared for [Sport(s)]: _____ Reason: _____Recommendation: _____Name of physician/nurse practitioner/physician a

Pre-Participation Physical Evaluation HISTORY This page to be completed by student and parent/guardian Name _____ Sex _____ Age _____ Date of Birth _____

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  Evaluation, Physical, Participation, Pre participation physical evaluation

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