MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C7A90B.73A695A0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C7A90B.73A695A0 Content-Location: file:///C:/E06C2CF7/LB.ExamformGRANDVIEW.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" HICKORY HIGH SCHOOL ATHLETICS

GRANDVIEW<= /st1:place> MIDDLE SCHOOL ATHLETICS

Pre Participation Medical Examination

 

Athlete’s Name _________________________________   Sport ____________________

 

Address _______________________________________ Grade __= __ Date of Birth __________

 

Ci= ty _____________ State= ___= __ Zip ____________ Home Phone Number_________________

 

 

Blood Pressure _______ Weight ____ Height ______ Vision:= R _____ L _____Cont= acts Glas= ses

 

    =             &nb= sp;       Normal        &= nbsp;     Abnormal        &= nbsp; Description of Abnormalities

 

ENT   &nb= sp;            =   _____        &= nbsp;      _____   _____________________________= ____________

Heart   &= nbsp;            _____        &= nbsp;      _____   _____________________________= _____________

Lungs    =            _____        &= nbsp;      _____   _____________________________= _____________

Abdomen   = ;       _____        &= nbsp;      _____   _____________________________= _____________

Neurological   = ;   _____        &= nbsp;      _____   _____________________________= _____________

Skin   &n= bsp;            = ;  _____        &= nbsp;      _____   _____________________________= _____________

Genitourinary  = ;   _____        &= nbsp;      _____  ___________________________________________

(males only)

 

Knee   &n= bsp;            = ; _____        &= nbsp;      _____   _____________________________= _____________

Ankle   &= nbsp;            _____        &= nbsp;      _____   _____________________________= _____________

Feet   &n= bsp;            = ;  _____        &= nbsp;      _____   _____________________________= _____________

Shoulder  &nbs= p;        _____        &= nbsp;      _____   _____________________________= _____________

Elbow   &= nbsp;           __= ___        &= nbsp;      _____   _____________________________= _____________

Wrist   &= nbsp;            _____        &= nbsp;      _____   _____________________________= _____________

Back   &n= bsp;            = ; _____        &= nbsp;      _____   _____________________________= _____________

 

Flexibility  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;     Shoulder

    =         Hamstrings        _____        &= nbsp;           &nbs= p;      Internal Rotation _____

    =         Heel Cords      &n= bsp; _____        &= nbsp;           &nbs= p;      External Rotation      = ;     _____

    =         Hip Flexors      =   _____        &= nbsp;              &= nbsp;   Abduction        &= nbsp;           &nbs= p; _____

    =         Lumbar Spine    _____        &= nbsp;           &nbs= p;      Flexion        &= nbsp;           &nbs= p;     _____

    =         Cervical Spine    _____        &= nbsp;           &nbs= p;      Extension        &= nbsp;           &nbs= p; _____

 

I have reviewed the data above, reviewed his/her medical history form and make the following recommendations for his/her participati= on in athletics.

 

    =         Full participation  _____        &= nbsp;           &nbs= p;     Limited Participation          &= nbsp;        _____

    =         No participation   _____        &= nbsp;           &nbs= p;     Needs Additional Evaluation   &nbs= p;    _____

 

If not cleared for full participation, give reasons & recommendations: _____________________________

________________________________________________________= ____________________________

 

Physician Signature ________________________________________________ Date ______________

    =             &nb= sp;            =        (Lice= nsed to practice medicine in NC)

Address __________________________________________        &= nbsp;           &nbs= p; Phone _____________ _________________________________________________<= /span>

    =         =

 

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   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;    

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