Benedictine University

Athletic Training

5700 College Road

Lisle, IL 60532

Phone: (630) 829-6152  Fax: (630) 960-0899

 

 

Athlete’s Name: ________________________________                SS#: _____________

 

Sport: ______________________     DOB: ________________     Sex: _____M _____F

 

Campus Address: ______________________________________________    Phone #: _____________

 

Parent/Guardian: ______________________________________________    Phone #: _____________

 

Home Address: _______________________________________   City: ______________    State: _____

                                                                                                                                                               

    Year  1  2  3  4

__________________________________________________________________________________________________________________________________________________________________________________________

 

ATHLETIC PHYSICAL EXAMINATION FORM

(Must be completed by a physician)

 

Height (in): _____      Blood Pressure: ____ / ____    Vision Left: ____ / ____

 

Weight (lbs): ____      Pulse (bpm): ____________     Vision Right: ____ / ____

 

% BF (optional): ______

 

Urine:

                        Specific Gravity ______        Protein ______           Glucose ______

 

 

GENERAL PHYSICAL EXAMINATION (completed by physician)

 

                Normal                  Abnormal                                                                              Comments

                   (   )                      (   )             Respiratory                 ________________________________              

   (   )                      (   )             Cardiovascular            ________________________________

               (   )                      (   )             Abdomen                    ________________________________

               (   )                      (   )             Hernia/genital             ________________________________

               (   )                      (   )             Skin                             ________________________________

               (   )                      (   )             Neurological               ________________________________

               (   )                      (   )             Dental/Mouth             ________________________________

               (   )                      (   )             Ears – general (canals)  ________________________________

               (   )                      (   )             Eyes (pupils, lids, conjunctiva, etc.) ___________________________

               (   )                      (   )             Head, Neck, and Face            ________________________________

               (   )                      (   )             Nose and Sinuses       ________________________________

               (   )                      (   )             Throat                         ________________________________

               (   )                      (   )             Lymphatics                 ________________________________

               (   )                      (   )             Psychological (if pertinent)_______________________________

 

Other: ________________________________________________________________________________

 

 

 

 

ORTHOPAEDIC PHYSICAL EXAM (completed by physician)

 

                Normal                  Abnormal                                                                              Comments

                   (   )                      (   )             Flexibility                    ____________________________

               (   )                      (   )             Neck/C-spine              ____________________________

               (   )                      (   )             Shoulders                    ____________________________

               (   )                      (   )             Elbows                                    ____________________________

               (   )                      (   )             Wrists/Hands              ____________________________

               (   )                      (   )             Hips                            ____________________________

               (   )                      (   )             Trunk/Spine                ____________________________

               (   )                      (   )             Knees                         ____________________________

               (   )                      (   )             Ankles                                    ____________________________

               (   )                      (   )             Feet                             ____________________________

               (   )                      (   )             Posture                       ____________________________

               (   )                      (   )             Leg Length                 ____________________________

               (   )                      (   )             Neurological (if needed)  ____________________________

 

Other: ________________________________________________________________________________

 

________________________________________________________________________

 

 

PARTICIPATION STATUS (determined by physician)

 

____ NO RESTRICTION for intercollegiate athletic participation

 

____ RESTRICTED PARTICIPATION to ___________________________________

 

 

I certify that I have on this date reviewed the history and examined this student-athlete.

 

Date of Examination: _________________ Physician Signature: _______________________________

 

Physician’s Address: ____________________________________________________________________

 

City: __________________ State: __________ Zip Code: _____________ Phone:__________________