Athletic Year

FORM B- 1 3 5
2015-2016 SACRED HEART UNIVERSITY INTERCOLLEGIATE ATHLETICS MEDICAL CLEARANCE
PRE-PARTICIPATION PHYSICAL EXAMINATION FORM
NAME: ________________________________________________________ SPORT(S): _________________________________

DATE OF BIRTH: _________________ __________________ CELL PHONE #: _____________________________________

ADDRESS: _______________________________________________________________________________________________________
(STREET) (CITY) (STATE) (ZIP CODE)
===============================================DO NOT WRITE BELOW THIS LINE==============================================
PHYSICIAN EXAMINATION
STUDENT ATHELTE IS CLEARED FOR ALL PHYSICAL ACTIVITY: □ YES □ NO □ LIMITED
PLEASE EXPLAIN ANY LIMITATIONS OR RESTRICTIONS_____________________________________________________________
1. HEIGHT: _______________________________
11. NOSE: _________________________________
2. WEIGHT: _______________________________ SEPTAL DEFECT: ___________________
OBSTRUCTION: ____________________
3. BMI: ____________________________________
12. LYMPH NODES: ________________________
4. BLOOD PRESSURE: ______________________
13. LUNGS: _______________________________
5. PULSES: ________________________________ BREATH SOUNDS: _________________
OTHER: __________________________
6. SKIN: __________________________________
RASHES: __________________________ 14: HEART: _______________________________
OTHER: ___________________________ SIZE: _____________________________
RHYTHM: _________________________
7. HEAD: _________________________________ MURMUR: _________________________
OTHER: ___________________________
8. EYES: _________________________________
EOM: _____________________________ 15. ABDOMEN: ___________________________
PUPIL SIZE: ________________________ LIVER: ___________________________
LIGHT REFLEX: _____________________ SPLEEN: _________________________
OTHER: ___________________________ MASSES: _________________________
TENDERNESS: ____________________
9. EARS: _________________________________ OTHER: __________________________
TYMP. MEM.: _______________________
CANAL: ___________________________ 16. HERNIA: ______________________________
OTHER: ___________________________
17. GENITALIA: ___________________________
10. THROAT/MOUTH: _________________________

18. PHYSICAL STIGMATA OF MARFAN’S SYNDROME: __________________________________________________________

19. UPPER / LOWER EXTREMITIES: _________________________________________________________________________

_________________________________________________________________________________________________________

20. SPINE/TORSO: _______________________________________________________________________________________

_________________________________________________________________________________________________________

21. RESTRICTIONS & LIMITATIONS: _________________________________________________________________________

_________________________________________________________________________________________________________

22. CURRENT MEDICATIONS: ______________________________________________________________________________

23. ADD/ADHD DIAGNOSIS YES NO

* (Please include Form E, documentation required by NCAA.)
24. COMMENTS: ________________________________________________________________________________________
_________________________________________________________________________________________________________

_____________________________________________ ___________________________________________
(EXAMINING PHYSICIAN’S NAME) (SIGNATURE)
______________________________________________ ___________________________________________
(DATE) (PHONE #)