Fillable Northern Essex Community College Athletic Participation Physical Exam (Northern Essex Community College)

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Northern Essex Community College Athletic Participation Physical Exam (Northern Essex Community College)

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Northern Essex Community College
Athletic Participation Physical Exam Form
Name _______________________________________________________________Date_______________ DOB _______________
Address ____________________________________________________________________________________________________
(Street) (City) (State) (Zip)
Home Phone ____________________________________________ Cell Phone __________________________________________
Circle all programs you plan to participate in:
W. Volleyball
Cro
ss Country
M. Basket
ball M. Baseball
Track & Field Softball
**BOTH SIDES OF THIS FORM AND THE ATTACHED IMMUNIZATION FORM MUST BE FILLED OUT COMPLETELY AND RETURNED!**
Part I – Medical History
This form must be completed by the student and signed, prior to the physical examination, for review by examining physician.
Explain all “Yes” answers below:
Yes No Has the student had any?
1. _____ _____ Hospitalizations? _____ _____
2. _____ _____ Surgery? _____ _____
3. _____ _____ Chronic or recurrent illness? _____ _____
4. _____ _____ Illness lasting longer than 1 week? _____ _____
5. _____ _____ Missing organs? _____ _____
6. _____ _____ Allergies to medications, insects, food, seasonal? _____ _____
7. _____ _____ Skin problems/disorders? _____ _____
8. _____ _____
Problems with heart, blood pressure, or cholesterol?
9.
_____ _____ Racing of your heart or skipped heartbeats?
__________
10. _____ _____ Chest pain, dizziness, or fainting with exercise?
________
11. _____ _____
Concussions, unconsciousness, or extremity numbness?
Yes No Has the student had any?
12. Headaches with exercise?
13. Confusion or memory loss after head injury?
14. Epilepsy or other seizures?
15. Asthma?
16. Diabetes?
17.
Heat exhaustion, heat stroke, or heat cramps?
18. Eyeglasses or contact lenses?
Females Only
How many periods have you had in the last 12 months?
What was the longest time between your periods last year?
Please explain all “Yes”answers________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
List all medications you are currently taking (include birth control pills, asthma inhalers, herbal and sport related supplements.)___________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
List injuries and surgeries to the following areas: Please be specific with details and dates.
Concussion/Head Injury/ “Bell Rung” ______________________________________________________________________________
______
__________________________________________________________
________________________________________________________________
___________________________________________________________________
___________________________________________________________________
________________________________________________________________
____________________________________________________________________
___________________________________________________________________
___________________________________________
___
___
______________________________
______________________________
_______ ___
______Back
Nec
k____________________________________
Shoulders________________________________
Elbows/Wrists/Hands/Fingers________________
________________________________________
_________________________________________________________Hips/Knees_________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________ _____________________
_________________
Ankles
/Feet/Toes________________
Student’s Signature_________________________________________________________________Date_______________________
Signing this form authorizes the release of physical exam records/information to the Northern Essex Community College Athletic Department
(OVER)
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signature
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Part II – Physical Examination
To be completed by MD, DO, PA, DC, or ARNP
Athlete’s Name__________________________________DOB________________
_S
port Participation_________________________
Height__________ Weight__________ BP__________ P__________Vision R:__________ L:__________ Corrective Lenses? Y N
)
FINDINGS
Mental/Emotional Status
HEENT
Skin
Neck, Thyroid
Lungs
Lymph Nodes
Abdomen
Extremities/Spine
Neurological
Genitals/Hernia
Heart
(Murmur/Dysrhythmia?
Femoral Artery Pulses
Recognition of Marfan
Syndrome
Pertinent Past Medical
History
Current Medications
Allergies to
Meds/Food/Other
Sickle Cell Trait
Additional Comments regarding abnormal findings___________________________________________________________________
_____________________________________
______
_______________________________
_____
_________________________________________________________________
______________________________________________________________________
Athletic Participation Recommendations
I have reviewed the data above, including the athlete’s medical history form and make the following recommendations for
his/her participation in athletics.
____
CLEARED WITHOUT RESTRICTIONS
____ Cleared AFTER further evaluation or treatment for ______________________________
_____________________________
_____________________________ ______________________ _______________
_______________
_ _______________ ________________________________________
____ NOT CLEARED due to
Other recommendations ______________________________________________________________________________
Physician Signature
(MD, DO, PA, DC ARNP)
_________________________________________ *Date of Examination* ____________________
Examiner’s Name and Degree (Print) _________________________________________ Phone ___________________
Address _________________________________________________________________Date Signed ________________
Revised 5/2015
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Northern Essex Community College Athletic Participation Physical Exam (Northern Essex Community College)

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Completed 26 July 2020

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