Ancilla Athletic Physical (Please Print)

NAME____________________________________________ SCHOOL YEAR______ AGE______

SCHOOL ADDRESS_________________________________CITY_____________STATE______ZIP________                 

HOME ADDRESS___________________________________CITY_____________STATE______ZIP________
 
HIGH SCHOOL ATTENDED___________________________CITY_____________STATE______ZIP________

PARENT'S NAME___________________________________PARENT'S PHONE__________________________

SCHOOL PHONE NUMBER___________________________SPORT(S)______________________

Circle One
YES   NO   1. Has had injuries requiring medical attention          YES   NO   2. Has had injury lasting more than a week

YES   NO   3. Is currently under physician's care                            YES   NO   4. Currently takes medication

YES   NO   5. Wears glasses (Contact lenses YES   NO)             YES   NO   6. Has had a surgical operation

YES   NO   7. Has been in the hospital        

YES   NO   8. Do you know of any reason why the individual should not particapate in all sports?

Please explain any YES answers to the above questions __________________________________________________

______________________________________________________________________________________________

YES   NO   9. Has had Poliomyelitis                                      YES   NO  10. Has had a dental check-up within the past 6 months

YES   NO  11. Most recent tetanus toxoid immunization       DATE:__________________

12.  List known allergies _______________________________________________________________________


Physician's Certificate

NAME___________________________________AGE________HEIGHT______WEIGHT_______ B/P _____________

EXAMINATION: (Please Circle)         SATISFACTORY         UNSATISFACTORY         NOT EXAMINED

VISION ______________________________________ HEARING __________________________________________

RESPIRAORY _________________________________CARDIOVASCULAR __________________________________

LIVER, SPLEEN, KIDNEY __________________________________SKIN ____________________________________

HERNIA, GENITALIA ______________________________________NEUROLOGICAL ___________________________

MUSCULOSKELETAL _____________________________________OTHER __________________________________

I CERTIFY THAT I HAVE EXAMINED THIS STUDENT-ATHLETE AS INDICATED AND FIND HIM/HER PHYSICALLY ABLE TO COMPETE IN SUPERVISED COLLEGE ATHLETICS AT ANCILLA COLLEGE.

LIST SPORTS NOT QUALIFIED_________________________________________________________

PHYSICIAN SIGNATURE__________________________________________________ DATE ___________________

PHYSICIAN ADDRESS_______________________________________CITY_____________STATE______ZIP________