School Sports Physical Examination Form
Student Information
Student Name
Date of Birth
Grade
School Name
School Year
Parent/Guardian Name
Phone Number
Medical History
Allergies
Current Medications
Past Illnesses/Injuries
Vital Signs
Height
Weight
Blood Pressure
Pulse
Physical Examination
Vision
Hearing
Exam Notes / Abnormal Findings
Participation Clearance
Cleared for all sports
Cleared with restrictions
Not cleared
If restrictions or not cleared, describe:
Examiner Name
Examiner Signature
Date