Grade for
Student Name____________________________________________________________________2009-2010 ____________
Last First
PLAINFIELD COMMUNITY MIDDLE SCHOOL ATHLETIC PHYSICAL FORM
Explain “YES” answers below
Explain “YES” answers below
Circle
Circle
Height Weight BP Pulse
Vision
R 20/
L 20/
Corrected: Y N
Pupils (circle) Equal/Unequal R>L
L>R
CLEARANCE: (circle appropriate answer)
1) CLEARED 2) Cleared after completing evaluation/rehabilitation for: ___________________________________________
3) NOT cleared due to:___________________________________Recommendation:______________________________________
Signature of physician________________________________________________________________________Date_____________
Name and Address of physician_________________________________________________________________________________________
I hereby certify that this athlete was examined by me. At that time, no physical condition was detected
which would reasonably be anticipated to render this athlete physically unfit to engage in any sport, except those circled below:
BASKETBALL, CROSS-COUNTRY, SOCCER, FOOTBALL, GOLF, BASEBALL, SOFTBALL, SWIMMING, TENNIS, TRACK, VOLLEYBALL WRESTLING
Have you ever been hospitalized?
Y
N
Has anyone in your family died of heart problems or a sudden death before
age 50?
Y
N
Have you ever had surgery?
Y
N Has anyone in your family had Marfan’s syndrome?
Y
N
Are you presently under a doctor’s care?
Y
N Do you have any skin problems (itching, rash, acne)?
Y
N
Are you presently taking any medications or pills?
Y
N Have you ever had a head injury?
Y
N
Do