Woodland Park Middle School

Cultivating leadership, compassion, and perseverance

  • WPMS Physical Exam Form

    By

    ____________________________________________________        ____________________

    STUDENT’S NAME (Please Print)                                                                          Date of Birth

     

    PHYSICAL EXAMINATION                   WPMS Middle School Sports Program

    To be completed by medical personnel *

     

    Height: ________          Weight: ________          BP: _______ / _______          Pulse: ________

     

    Vision (optional)            Left eye: 20/______       Right eye: 20/______

     

    KEY:    ü = WNL      X = Item omitted      È = see “Notes” below

      1.

    Skin

     

     

    11.

    Extremities

     

      2.

    Head

     

     

    12.

    Neurological

     

      3.

    Eyes (PERL, EOMI, Fundi)

     

     

    13.

    Orthopedic

     

      4.

    Ear, Nose, Throat

     

     

     

    Cervical spine/back

     

      5.

    Neck

     

     

     

    Arms / elbows / wrists / hands

     

      6.

    Lymphatic

     

     

     

    Hips

     

      7.

    Cardiovascular

     

     

     

    Knees

     

      8.

    Heart (murmurs?)

     

     

     

    Ankles / feet

     

      9.

    Abdomen

     

     

    14.

    Developmental

     

    10.

    Genetalia (including hernia)

     

     

     

    Tanner staging (1-5)

     

     

    Please initial or check one of the two clearance options below:

     

    1.    _____    Full, unrestricted clearance

    or

    2.    _____    Not cleared.  Needs clearance by specialist(s) as indicated below and in Notes.

     

                         ____Orthopedist     ____Cardiologist        ____Other: _________________________

     

    Notes:  ________________________________________________________________________

     

                ________________________________________________________________________

     

                ________________________________________________________________________

     

    *   Effective May 4, 2011, screenings may only be performed by a licensed MD, DO, PAC, or NP

    **  Screening must be performed AFTER May 25, 2016 for 2016-2017 school year participation.

     

    Athletic Screening Performed By:                                                             Screener’s Office Stamp

     

     

     

     

     

    __________________________________________________

    Print Name/Title                        (M.D. / D.O. / P.A.C. / N.P.)

     

     

    _______________________________          _______________

    Signature                                                        Date Signed

    Physical_Exam_Form_WPMS 16.docx 21.37 KB (Last Modified on June 8, 2016)
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