Student Name: _____________________________________Date of Birth: __________________
Address: _______________________________________________________________________
Parent/Guardian: ___________________________________ Home Phone: _________________
School: ______________________________________________Grade: ____________________
Parent or guardian, please answer the following:
Any medical problems or health concerns?
No
Yes
Any hearing, vision or speech problems?
No
Yes
Contact lens, glasses or hearing aids?
No
Yes
Any allergies?
No
Yes
Any medications?
No
Yes
Is this physical a sports participation exam?
No
Yes-please answer questions on
back of this form.
If yes, please list any information for the above questions: _________________________________
Physician Recommendation:
Date of Exam: ___________________________________________________________________
Height: __________ Weight: __________ B.P._________ Pulse _________
Student’s immunizations are current.
Yes
No Immunizations given today: ________
Student can participate in all school activities.
Yes
No
Student can participate in athletics¹.
Yes
No
If no, physician recommendation: ___________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I have interviewed and examined this student.
Physician name (print):
Address:
Phone:
Physician signature: ______________________________________________________________
1
For a detailed listing of participation recommendations, see Kurowski & Chandran,The Preparticipation Athletic Evaluation,
AFP May 1, 2000, Vol. 61, p 2683, or http://www.aafp.org/afp/20000501/2683.html
Revised 1/07
Linn-Mar Community Schools
Student Physical Examination Form
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