York College of Pennsylvania Pre-Participation Physical Form

York College of Pennsylvania Pre-Participation Physical Form

Sport______

Last Name______First Name______MI

Medical Exam / Sophomore / Junior / Senior
1. Age
2. Weight
3. Height
4. BP/BP recheck
5. HR/HR recheck
6. Ears
7. Eyes
8. Nose
9. Throat
10. Lymph nodes
(Thyroid)
11. Respiratory
12. Cardiovascular
(Reg. Rhythm)
(No murmer)
(Valsalva Man.)
13. Hernia(male)
(Testes WNL)
14. Skin
15. Gross Neurologic
Comments
Date of Exam / / / / / / / / /

Physician’s Statement of Health:

I certify that I have examined the above athlete and have found no gross evidence of any abnormality that will interfere with his or her participation in intercollegiate sports.

Physician’s Signature______

Physicians Printed Name______

Address______

Phone #______

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