OLD ROCHESTER Physical Form

OLD ROCHESTER Physical Form

Student’s name: ______

Grade or Year of Graduation entered this fall: ______

THIS SECTION IS FOR YOUR CHILD’S PHYSICIAN TO COMPLETE.

Date of Exam: ______

BP: ______Height ______Weight ______

Check if results are normal.

____ Ears: Hearing Tested: Right ear ______pass / fail Left ear: ______pass / fail

____ Pupils: equal / non-equal | reactive / no-reactive

EXPLAIN: ______

Vision (if tested): Right eye: 20 / Left eye: 20 /

____ Mouth ______

____ Skin ______

____ Lungs ______

____ Heart Pulses = equal / unequal ______

Murmur ______

Rhythm ______

____ Lymphatic Cervical ______

Auxiliary ______

____ Abdomen Liver – N / ABN Spleen – A / ABN Hernia – Yes / No

____ Neurological exam: N / ABN EXPLAIN: ______

____ Orthopedics Cervical spine/ coliosis______

Shoulders ______

Arm / Elbow / Wrist / Hold ______

Knees ______

Ankles ______

Spines ______

____ No chest pain or fainting with exertion

____ Full participation with selected sports

____ Limited participation in selected sports ______

____ NO PARTICIPATION

Does the child have or has he/she had any of the following?

____ Asthma / Allergies ____ Mononucleosis

____ Pneumonia ____ Heart murmur / problems

____ Operations ____ Hepatitis

____ Rheumatic Fever ____ Bronchitis

____ Kidney disease / injury ____ Head injury

____ Heat Stroke / Exhaustion ____ Concussion

____ Diabetes ____ Serious dental problems

____ Menstrual problems ____ Tumors

____ Blood disorders ____ Fractures, Sprains, Dislocations

Please explain any other illness or injury that the coach needs to be aware of: ______

______

Physician’s Signature: ______Date ______