ANTONIAN MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM by umsymums38

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									                  ANTONIAN MEDICAL HISTORY AND PHYSICAL EXAMINATION FORM
                     (***Must be completed before a student participates in any practices)
                                                2009-2010

Students Name _____________________________________________ Circle one                             Male Female

Parents/Guardian ___________________________________________ Students Date of Birth ________________

Family Doctor or Clinic’s Name _______________________________ Phone # ____________________

Family Dentist or Clinic’s Name _______________________________ Phone # ____________________

As a minimum requirement, this Physical Examination Form must be completed prior to high
school athletics competition. It must be completed if there are yes answers to specific question on
the student’s MEDICAL HISTORY FORM above.

           COM PLETE ALL BLANKS SPACES- (to be completed by examining physician)

Weight _________          Height _________    Pulse _________Blood Pressure_________

LEGEND:                   N= normal           X= abnormal NE= not examined

General Body Build____Skin____Eyes____Ear____Nose____Throat____Neck____Teeth____

Lungs_____Heart_____Chest_____Liver_____Spleen_____Spine_____Abdominal masses_____

JOINT FUNCTION: Shoulders_____Elbows_____Wrists_____Hands_____Hips_____

Knees_____Ankles_____Feet_____Neurological_____Hernia_____Genitalia (Male only)_____

Description of Abnormal Findings: ________________________________________________

I certify that I have examined this student and he/ she may compete in supervised school athletic activities with the
exception of the following specific activities (please circle any activity from which this student should be
excluded):

Baseball     Basketball     Cross Country    Golf   Soccer    Softball   Volleyball   Cheerleading

Dance      Track & Field     Football   Swimming     Tennis

Special Instructions or special limitations:_____________________________________________
Printed Name of Physician_________________________________________________________
Physician’s Address_____________________________________Zip_______________________
Physician’s Signature___________________________________Exam Date_________________

								
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