Print Name: Birthday Key X = Normal
Last First Day Mo Yr
Physical Screening / Grade 9 / Grade 10 / Grade 11 / Grade 12Date
/ Date / Date / DateHeight /
Weight /
Blood Pressure/Pulse /
BP
/P
/BP
/P
/BP
/P
/BP
/P
Vision /20/
/20/
/20/
/20/
/20/
/20/
/20/
/20/
APPEARANCE
/Eyes/Ears/Nose/Throat /
Lymph Nodes /
Heart /
Pulses /
Lungs /
Abdomen /
Genitalia (males only) /
Skin /
MUSCULOSKELATAL
/Neck /
Back/Spine /
Shoulder/Arm /
Elbow/forearm /
Wrist/hand /
Hip/thigh /
Knee /
Leg/ankle /
Foot /
NOT CLEARED
/Reason/Recommendation /
Cleared /
Cleared after completing evaluation/rehabilitation for /
Examiner’s Signature /
Examiner’s Name
(please print) /
Examiner’s Address /
Anticipatory Guidance / /
Y
/N
/ /Y
/N
/ /Y
/N
/ /Y
/N
(Opitional) /Injury Prevention
/ / /Injury Prevention
/ / /Injury Prevention
/ / /Injury Prevention
/ /Psych/Social
/ / /Psych/Social
/ / /Psych/Social
/ / /Psych/Social
/ /Tobacco/Alcohol/
Drugs/Steroids / / /Tobacco/Alcohol/
Drugs/Steroids / / /Tobacco/Alcohol/
Drugs/Steroids / / /Tobacco/Alcohol/
Drugs/Steroids / /Eating Disorders
/ / /Eating Disorders
/ / /Eating Disorders
/ / /Eating Disorders
/ /Diet/Fitness
/ / /Diet/Fitness
/ / /Diet/Fitness
/ / /Diet/Fitness
/ /Sexual Activity/
STD / / /Sexual Activity/
STD / / /Sexual Activity/
STD / / /Sexual Activity/
STD / /In an emergency, due to illness or accident, when you cannot be contacted, the Ceres Unified School District authorities have my permission to use their best judgment in the interest of the health of the above named student. No expenses involved will be paid by the school district.
Signed______Date______