HEALTH PHYSICAL FORM - Huntington University

PHYSICIAN’S EXAMINATION FOR ALL STUDENTS
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Last name First name M.I. Date of Birth
Height: __________ in. Weight: __________ lbs. Blood Pressure: __________mmHg Pulse: __________BPM
Vision: Right: __________ Left: __________ Corrected: Contacts / Glasses Eyes: Pupils Reactivity _________
ORTHOPEDIC SCREENING Normal Abnormal Specific Findings
Neck ROM /MMT □ □
Stability □ □
Back ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □
Deformity □ □ Scoliosis / Lordosis / Kyphosis / Valsalva
Shoulder ROM /MMT □ □ Impingement
Stability □ □ Subluxation / Dislocation / AC Joint
Elbow / Wrist / Hand ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Valgus / Varus
Hip / Thigh ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Subluxation / Dislocation
Knee ROM /MMT □ □ Hyperextension / Hyperflexion
Stability □ □ Valgus / Varus / Ant. Drawer / Post. Drawer
Shin / Ankle / Foot ROM /MMT □ □
Stability □ □ Pronation / Supination / Rigid Flat Feet
Other □ □ Bunions / Corns/ Blisters
Region Normal Abnormal Region Normal Abnormal
Nose & Throat □ □ Abdomen □ □
Dental Status □ □ Tenderness □ □
Pharynx □ □ Masses □ □
Neck / Thyroid □ □ Liver □ □
Ears / Hearing □ □ Spleen □ □
Canals □ □ Kidneys □ □
Skin Condition □ □ Scars □ □
Nails □ □ Genitalia □ □
Hair □ □ Hernia □ □
Chest □ □ Pelvic □ □
Pulmonary □ □ Scrotum / Testes □ □
Breasts □ □ Extremities □ □
Axillary Nodes □ □ Movement □ □
Heart □ □ Arms □ □
Rhythm □ □ Legs □ □
Murmurs □ □ Hands □ □
IMMUNIZATIONS RECORD: THIS SECTION MUST BE COMPLETED AT THE TIME OF THE PHYSICAL. ALL STUDENTS, REGARDLESS OF AGE, MUST HAVE DOCUMENTED
PROOF OF IMMUNIZATIONS. (LIST DATES)
DT/DPT _______________1 st _______________ 2 nd _______________ 3 rd Booster _______________ 1 st _____________ 2 nd ___________
OPV/IPV ______________ 1 st _______________ 2 nd _______________ 3 rd Booster _______________ 1 st
MMR @ 1 yr.: _______________ Booster (kindergarten or 6 th grade): _______________ Tetanus Booster (Effective 7-10 years):_________
TB Test (Mantoux) Current this year for 1 st time students: Date _______________ Date Read _______________ Results____________________
Meningitis vaccine _______________ (This vaccine is required of all 1 st year and transfer students.)
SUGGESTED VACCINES ONLY – (Not Mandatory)
Hepatitis B _______________ 1 st _______________2 nd _______________ 3 rd
Hepatitis A _______________ 1 st _______________ 2 nd
ON THE BASIS OF THIS EXAMINATION, I APPROVE THIS STUDENT’S PARTICIPATION IN: (please circle)
Intercollegiate Sports/Cheerleading with no restrictions: YES NO
Physical Education with no restrictions: YES NO
Intramurals with no restrictions: YES NO
Please note any restrictions or limitations:______________________________________________________________________________
Physician’s Name __________________________________ Address _____________________________________Phone_______________
(As the physician, this student has received the required examination and has received ALL necessary immunizations.)
Physician’s Signature __________________________________________ Date of Exam_______________________________
PLEASE RETURN TO: HUNTINGTON UNIVERSITY, STUDENT DEVELOPMENT
2303 COLLEGE AVENUE, HUNTINGTON, IN 46750 Questions? Call 260-359-4026
4. Revised 3/10