2022-2023 NEW FAMILY APPLICATION | Page 30

PHYSICAL EXAMINATION - ( Categories may be added or deleted ) ( To be completed by Physician-Check appropriate Column )
SYSTEM
NORM .
ABN .
SYSTEM
NORM .
ABN .
Urinalysis
Thyroid
Vision
Chest
Blood Pressure
Lungs
Pulse Rate
Heart
Ears
Abdomen
Nose
Hernia
Throat
Genitalia / Testicular Exam
Teeth-Cavities
Neuralgic
Orthopedic
Muscular
RECOMMENDATIONS : _________________________________________________________________________________
___________________________________________________________________________________________________
I certify that I have examined the above student and recommend him as being able to compete in supervised athletic activities as listed below . Please circle appropriate ones .
BASKETBALL SOCCER CHEERLEADING A current year physical is one given on or after May 1 of the previous school year .
Date : ____________ Signature of Examining Physician : _______________________________________________
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