CHESTNUT HILL COLLEGE

PHYSICAL EXAMINATION FOR ATHLETES

__________ __________________________________ ____________ ________________

Date Name Birth date Sport

Medications (presently taking/dose) ________________________________________________

Allergies (drug/insect/other) ______________________________________________________

Previous injuries/surgeries ________________________________________________________

Head injuries __________________________________________________________________

MEDICAL PHYSICAL Ht:_________ Wt:_________ BP______/______

Pulse: ________beats/min. Eyes: R 20/_____ L 20/_____

HEENT_______________________________________________________________________

Lymph Glands__________________________________________________________________

Respiratory____________________________________________________________________

Cardiovascular_________________________________________________________________

Abdomen_____________________________________________________________________

Genitalia______________________________________________________________________

Neurologic_____________________________________________________________________

Orthopedic_____________________________________________________________________

Sickle Cell Trait Status___________________________________________________________

Other_________________________________________________________________________

PARTICIPATION PENDING____________________________________________________

LIMITATIONS________________________________________________________________

CLEARED FOR PARTICIPATION: YES_____ NO_____ DATE: ___________________

SIGNATURE ___________________________ PRINT NAME_________________________

DR/OFFICE STAMP ___________________________________________