UNIVERSITY OF TENNESSEE AT MARTIN

 ATHLETE PHYSICAL FORM

 

 

NAME:

SPORT:

HEIGHT:

WEIGHT:

BLOOD PRESSURE:

 

 

PULSE:

URINALYSIS:            Glucose:

 

Leuko:           pH:                SG:  

 

Protein:        Blood:            Ketones:

 

ENT/ABD/CHEST & LUNGS (TO BE FILLED OUT BY EXAMING PHYSICIANS)

 

 

 

LIMITATIONS TO PHYSICAL ACTIVITY:

 

 

 

I have examined the above named individual and find no reason to exclude him/her from intercollegiate sports activity.

 

Physicians Signature: ______________________  Date: _________________

 

ORTHOPEDIC EXAM (TO BE FILLED OUT BY EXAMING PHYSICIAN)

 

 

 

LIMITATIONS TO PHYSICAL ACTIVITY:

 

 

I have examined the above named individual and find no reason to exclude him/her from intercollegiate sports activity.

 

Physicians Signature: ______________________  Date: _________________

 

I HAVE DISCLOSED TO THE DOCTORS AND TRAINING STAFF MY COMPLETE MEDICAL HISTORY AND BELIEVE I AM PHYSICALLY FIT TO PARTICIPATE IN MY SPORT.

 

ATHLETE’S SIGNATURE: _______________________ DATE: _____________