Eureka College New Student Packet 2013-14

athleticphysical Pre-Participation PHYSICAL EXAM (Athletes Only. To be completed by Physician) Name __________________________________________________ Age____________ Date ________________ Height ___________ Weight ___________ Vision: Right 20/_____ MEDICAL Left 20/______ Blood Pressure ______ / ______ Heart Rate ______________ Corrected? NORMAL Yes No Contacts Glasses ABNORMAL FINDINGS Eyes/Ears/Nose/Throat Mouth and Teeth Lymph Nodes Heart Pulse Lungs Abdomen Skin Genitalia- Hernia (male) Musculoskeletal Neck Spine Shoulders Arms/Hands Hips Thighs Knees Ankles Feet Neuromuscular Sickle Cell Trait Test Further Medical Evaluation Required:________________________________________________________________ Cleared to Participate Not cleared to participate Date __________ Phone _______________ Print Name ______________________________________ Signature ____________________________________ (MD, DO, or PA only) 22

Eureka College New Student Packet 2013-14 | Page 22