Rowing Team Pre-Participation Physical Exam

Personal Information

Name

Date of Birth

Age

Gender Male Female Other

School/Club

Grade

---

Emergency Contact

Contact Name

Relationship

Phone

---

Medical History

Allergies Current Medications Medical Conditions Previous Injuries/Surgeries Heart Problems (e.g., chest pain, palpitations, fainting) Asthma/Breathing Issues Vision/Hearing Issues

---

Physical Examination

Height (cm)

Weight (kg)

Blood Pressure

Pulse

Musculoskeletal Examination Cardiopulmonary Examination Other Relevant Findings

---

Clearance

Participation Clearance Cleared Cleared with recommendations Not Cleared Recommendations/Restrictions

---

Examiner

Examiner Name

Date

Signature