Athlete Physical Exam Form PPE: Athlete Physical Examination Form Date of Examination * ATHLETE INFORMATION Athletic Organization * Name * Name First First Last Last Date of Birth * PHYSICIAN REMINDERS Consider additional questions on more-sensitive issues. Do you feel stressed out or under a lot of pressure? Yes No Do you ever feel sad, hopeless, depressed, or anxious? Yes No Do you feel safe at your home or residence? Yes No Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip? Yes No During the past 30 days, did you use chewing tobacco, snuff, or dip? Yes No Do you drink alcohol or use any other drugs? Yes No Have you ever taken anabolic steroids or used any other performance-enhancing supplement? Yes No Have you ever taken any supplements to help you gain or lose weight or improve your performance? Yes No Have you ever taken any supplements to help you gain or lose weight or improve your performance? Yes No Do you wear a seat belt, use a helmet, and use condoms? Yes No EXAMINATION Height * Weight * lbs Blood Pressure * Pulse * bpm Vision (Right Eye) * Vision (Left Eye) * Vision Corrected * Yes No MEDICAL Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse [MVP], and aortic insufficiency) * Normal Abnormal Appearance Findings * Eyes, ears, nose, and throat • Pupils equal • Hearing * Normal Abnormal Eyes, ears, nose and throat Findings * Lymph Nodes * Normal Abnormal Lymph Nodes Findings * Heart: Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver) * Normal Abnormal Heart Findings * Lungs * Normal Abnormal Lungs Findings * Abdomen * Normal Abnormal Abdomen Findings * Skin: Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or tinea corporis * Normal Abnormal Skin Findings * Neurological * Normal Abnormal Neurological Findings * MUSCULOSKELETAL Neck * Normal Abnormal Neck Findings * Back * Normal Abnormal Back Findings * Shoulder and Arm * Normal Abnormal Shoulder and Arm Findings * Elbow and Forearm * Normal Abnormal Elbow and Forearm Findings * Wrist, Hand and Fingers * Normal Abnormal Wrist, Hand and Fingers Findings * Hip and Thigh * Normal Abnormal Hip and Thigh Findings * Knee * Normal Abnormal Knee Findings * Leg and Ankle * Normal Abnormal Leg and Ankle Findings * Foot and Toes * Normal Abnormal Foot and Toes Findings * Functional: Double-leg squat test, single-leg squat test, and box drop or step drop test * Normal Abnormal Functional Findings * *Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combination of those. HEALTH CARE PROVIDER INFORMATION Health Care Provider Name * Health Care Professional's Name * Health Care Professional's Name First First Last Last Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Phone * Email * If you are human, leave this field blank. Submit Δ
