Montclair State University

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					Montclair State University                                          DATE:
2nd Year @ MSU Physical Form                                        SPORT:

 Name:                                               Age:          Male     Female     DOB:

 Height:             Weight:                     E-mail Address:                        SID#

 Dorm or Off Campus Address:


 Cell Phone:

 Home address:


 Parent/Guardian Name(s):

 Address (If different than above):

In case of an emergency and a Parent or Guardian can not be reached, please contact:

 Name:                            Relationship:

 Phone:                               Address:

Since your last PREPARTICIPATION PHYSICAL EXAMINATION, has there been a change in your medical
condition/history? Please respond to the questions below. If yes, please explain below.
                                                                                          YES NO
1. Are you presently taking any medication?
2. Do you have any allergies?
3. Are you wearing any dental appliances, hearing aids, glasses, or contacts?
4. Any surgeries in the last year?
5. Any injuries requiring rehabilitation and/or bracing?
6. Any automobile or other accidents that required medical attention/hospitalization?
7. Any fainting or dizzy spells, concussions, or periods of unconsciousness?
8. Women – Are your menstrual cycles regular?
9. Have you gotten chest pain or shortness of breath while exercising?
10. Are you taking any nutritional supplements your athletic performance?
11. Have you stopped or started smoking?
12. Have you experienced any abdominal/stomach problems?
13. Have you experienced any emotional or stress problems?
14. Are you currently under a doctor’s care for any reason?
15. Have any family members experienced any new conditions or diseases?
16. Have you been recently diagnosed with ADD or ADHD?
17. Do you or a family member suffer from Sickle Cell Anemia?
18. Have you been recently diagnosed with a mental illness?
19. Have you been recently diagnosed with a eating disorder?
20. Has a doctor denied or recommended against your participation in a sport or activity?

Explain any “yes” answers or to provide any other information.
For Staff use only:                         Physical Examination
                                    (To be completed by the physician or medical staff)

Blood Pressure:                                                Pulse Rate:

Orthopedic Exam/Assessment:                 Conducted by









I certify that I have reviewed the history and examined the above student and I recommend:

                                   Student is approved for full participation with no limitations.

                                   Student is approved pending additional information/tests.
                                   Once completed the student is approved for full participation.

                                   Student is approved for participation with limitations. Please explain.

                                   Student is referred to other health care professional prior to clearance.

                                   Student is not approved for participation.

Athletic Trainer/Physician/Nurse Practitioner/Physician Assistant’s Signature                   Date

Print Physician name & address or stamp -

STOP! - I attest that the above information is correct and complete to the best of my knowledge. I understand
that any medical information withheld, incomplete, or incorrect may result in incomplete or incorrect medical
treatment and may disqualify me from participation. I did not withhold any information about any physical
problems in order to participate. I did not withhold any information about any physical problems in order to
Athlete’s Signature                                                                                  Date

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