Read CIVILIAN STUDENT TRAINING PROGRAM text version

CIVILIAN STUDENT TRAINING PROGRAM

PREPARTICIPATION PHYSICAL EVALUATION Eff 6/2004 NAME: DATE OF BIRTH: Height: Weight: Pulse: BP: Vision: R 20/____ L 20/_____ Corrected: ____Yes _____No Pupils equal: Yes / No MEDICAL Appearance Eyes/Ears/Nose/Throat Lymph Nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder / Arm Elbow / Forearm Wrist/ Hand Hip / Thigh Knee Leg / Ankle Foot

CLEARANCE: ______ Cleared for all sports/activities ______ Not cleared Reason: Prescription Medications currently taking: (please list name/dosage)

NORMAL

ABNORMAL FINDINGS

INITIALS

Name of Medical Provider: Name of Facility: Address: Signature:

Phone: Title: Date:

Information

CIVILIAN STUDENT TRAINING PROGRAM

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