School Sports Physical Examination Form
Student Information
Student Name
Date of Birth
Grade
Parent/Guardian Name
Contact Number
Medical History
Please describe any past or current medical conditions:
Allergies:
Current Medications:
Physical Examination
Height
Weight
Blood Pressure
Pulse
Significant Examination Findings:
Physician's Clearance
Student is cleared for sports participation:
Yes
No
With restrictions
If any restrictions, specify:
Physician Name
Signature
Date