Physical Examination

Physical Examination

To be completed by the student’s health care provider. A physical examination is required annually.

Step 1 of 2

To be completed by the student’s health care provider. A physical examination is required annually.
Student’s Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female

Vitals

Height	Weight	Pulse	BP

Vision*

R 20/	L 20/	Corrected: Y N

MEDICAL
- Appearance
  - Normal
- Abnormal Findings
- Eyes check
  - Normal
- Abnormal Findings
- Ears check
  - Normal
- Abnormal Findings
- Nose check
  - Normal
- Abnormal Findings
- Throat check
  - Normal
- Abnormal Findings
- Lymph nodes
  - Normal
- Abnormal Findings
- Heart check
  - Normal
- Abnormal Findings
- Respiratory/Asthmatics ?
  - Normal
- Abnormal Findings
- Pulses: Simultaneous femoral and radial pulses
  - Normal
- Abnormal Findings
- Abdomen
  - Normal
- Abnormal Findings
- Skin (HSV, lesions suggestive of MRSA, tinea corporis)
  - Normal
- Abnormal Findings
- Have you traveled recently?
  - Yes
  - No
- Have you done covid test?
  - Yes
  - No
- If yes, What date?*
  MM slash DD slash YYYY
- What was the result?
  - Positive
  - Negative
Additional Immunization Information
- Genotype
  - Normal
- Genotype
- Neurologic
  - Normal
- Abnormal Findings
- Hepatitis B/C
  - Normal
- Abnormal Findings
MUSCULOSKELETAL
- Neck
  - Normal
- Abnormal Findings
- Back
  - Normal
- Abnormal Findings
- Shoulder/arm
  - Normal
- Abnormal Findings
- Elbow/forearm
  - Normal
- Abnormal Findings
- Wrist/hand/fingers
  - Normal
- Abnormal Findings
- Hip/thigh
  - Normal
- Abnormal Findings
- Knee
  - Normal
- Abnormal Findings
- Leg/ankle
  - Normal
- Abnormal Findings
- Foot/toes
  - Normal
- Abnormal Findings
- Functional (duck-walk, single leg hop)
  - Normal
- Abnormal Findings
Click "Next" to continue

CURRENT TREATMENT OR MEDICATION
Is student under any form of medical and/or psychological treatment or supervision? If so, please describe.
Is He/She allergic to any Medicine or Food?
PRE PARTICIPATION PHYSICAL EVALUATION CLEARANCE FORM
- Cleared for all sports without restriction
- Cleared for all sports without restriction with recommendations for further evaluation or treatment for:
Not cleared for
- Pending further evaluation
- For any sport
- For certain sport
Reason:
SIGNATURE REQUIRED
I have examined this applicant to Meadow Hall Education and find him or her to be in good general health with the exception of the conditions noted on the attached sheet. I am also giving such information about the applicant’s past medical history that I feel necessary for the proper medical attention to this applicant in case of illness or accident.
Name of Healthcare Provider*
Date*
MM slash DD slash YYYY
Address
Street Address City State / Province / Region Country
Phone Number
Signature of Health Care Provider

Please type name in full