Height ______Weight ______ BP _____/______ Pulse______

Vision R 20/____ L 20/____ Corrected? ____ Yes ____ No Pupils _____
 

	Normal	Abnormal Findings
Ears, Nose, Throat	__________________	__________________
Heart	__________________	__________________
Chest/Lungs	__________________	__________________
Skin/Lymphatic	__________________	__________________
Abdominal	__________________	__________________
Genitalia/Hernia	__________________	__________________

Musculoskeletal Examination          Examiner:__________________________________

	Normal	Abnormal Findings
Neck/Back	__________________	__________________
Upper Extremities	__________________	__________________
Lower Extremities	__________________	__________________
Flexibility	__________________	__________________

Optional Lab

Urine Sugar __________

Urine Protein _________

Urine Hematest _______

Official Recommendation
This athlete _____ may _____ may not compete in athletics based on the data gathered from this exam. Prior to participation, treatment or follow-up on the following in recommended:
Recommend further consultation with _____________________________
Signature of Physician: _____________________________ Date: ______