PHYSICAL EXAM FORM RET STU-ATH - Hartwick College
PHYSICAL EXAM FORM RET STU-ATH - Hartwick College
PHYSICAL EXAM FORM RET STU-ATH - Hartwick College
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Name: ________________________________________<br />
Date of Birth: ___________________<br />
Date of Exam: __________________ Sex: M F<br />
Sport (s):<br />
<strong>Hartwick</strong> <strong>College</strong> Student Athlete<br />
Annual Pre-Participation Examination<br />
This form MUST be completed by your health care provider and returned to Perrella Wellness Center at least 1 wk prior to<br />
sports participation. THERE WILL BE NO EXCEPTIONS.<br />
HISTORY<br />
No<br />
Yes<br />
Comments<br />
Congenital Problems:<br />
Injuries:<br />
Concussion, skull fracture or head injury<br />
Neck injury<br />
Stinger, burner, pinched nerve<br />
Back pain/injury<br />
Arm/shoulder<br />
Knee/ankle injury<br />
Stress fracture<br />
Cardiac: echo or EKG?<br />
Murmur<br />
Rheumatic fever<br />
High blood pressure or cholesterol<br />
Sudden cardiac death of relatives under age 50<br />
Other fainting?<br />
Respiratory:<br />
Asthma<br />
Shortness of breath<br />
Other fainting?<br />
Abdominal OR GU:<br />
Injury esp. spleen /kidney<br />
Surgery<br />
Hernia<br />
Testicular/ovarian<br />
Single organ<br />
Head:<br />
Vision problems<br />
Corrective lens/glasses or contacts<br />
Protective eye wear<br />
Loss of consciousness/ head injury<br />
Ear problems<br />
Seizures, blackouts, fainting<br />
Metabolic Disorders:<br />
Diabetes Mellitus<br />
Thyroid<br />
Bleeding problems<br />
Other
Name: _____________________________________ Date of Birth: _____________________<br />
HISTORY con't<br />
Smoking: Now<br />
In past<br />
Medication: Now<br />
Over the Counter<br />
Prescription<br />
In Past<br />
Other:<br />
Have you ever felt dizzy or passed out during<br />
exercise<br />
Allergies ( pollen, medications, food or stinging<br />
insects<br />
Mononucleosis within the past month<br />
Anemia<br />
Skin Disorders<br />
Eating disorders / nutrition concerns<br />
Other History / Comments:<br />
Women ONLY:<br />
Menstrual Cramps<br />
Date of last Period<br />
No<br />
Yes<br />
History reviewed by Heath Care Provider: Signature: _____________________________ Date: ______________<br />
<strong>PHYSICAL</strong> <strong>EXAM</strong>INATION<br />
Comments<br />
Height ________feet ________inches Weight __________ lbs. BMI: __________________<br />
Blood Pressure _______ / _______ (Rt. Arm sitting) Urine _________________________<br />
Pulse _______/min.<br />
Resp. Rate ___________/min.<br />
HEENT<br />
NECK<br />
CHEST / LUNGS<br />
HEART / VESSELS<br />
ABDOMEN<br />
GENITOURINARY<br />
HERNIA<br />
MUSC-SKEL<br />
NEURO<br />
PSYCHOLOGIC<br />
OTHER<br />
Not Normal<br />
Normal Limits Needed Comments<br />
/ No limits<br />
RESULT:<br />
No limitation for sport noted<br />
Limited Participation<br />
Specify limits: ___________________________________________<br />
Heath Care Provider Signature: ________________________________________ Date: __________________
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