CCS Athletics Medical Permission Form | Page 3

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. _________________________________________________________________________________ ___________________________________________________________________________________________________ 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: _________________________________________________