PHYSICAL EXAMINATION - (Categories may be added or deleted)
(To be completed by Physician-Check appropriate Column)
SYSTEM
Urinalysis
Vision
Blood Pressure
Pulse Rate
Ears
Nose
Throat
Teeth-Cavities
Orthopedic
RECOMMENDATIONS:
NORM.
ABN.
SYSTEM
Thyroid
Chest
Lungs
Heart
Abdomen
Hernia
Genitalia/Testicular Exam
Neuralgic
Muscular
NORM.
ABN.
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I certify that I have examined the above student and recommend him as being able to compete in supervised athletic
activities as listed below. Please circle appropriate ones.
BASKETBALL
SOCCER
A current year physical is one given on or after May 1 of the previous school year.
Date: ____________
Signature of Examining Physician: _________________________________________________