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department of athletics policies & procedures - UNC Wilmington ...

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Student-Athlete Signature<br />

Date<br />

Parent/Guardian Signature (if under 18 yrs. <strong>of</strong> age)<br />

Date<br />

Physical Examination<br />

Name<br />

______________<br />

Vital Signs<br />

Ht _____ft. _____in. Wt___________ lbs. BP _______/______ Pulse _________<br />

Comments if abnormal:<br />

Eye Examination<br />

Vision R 20 /______/_____ L 20 /______/_____ Corrected? Y N Contact Lenses? Y N<br />

□ PEERL □ EOMI Comments if abnormal :<br />

General Examination<br />

head<br />

ears<br />

mouth/ throat<br />

neck<br />

lungs<br />

Norm<br />

al<br />

Abn<br />

l<br />

Comments/details<br />

291

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