EASTERN WASHINGTON UNIVERSITY ATHLETIC TRAINING

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1 Pre-Physical Examination Date: Sport(s): Name: Date of Birth: Last First Middle Permanent Address: Phone: Street/PO Box City State Zip Parent or Legal Gaurdian: Relationship: Address: Phone: Street/PO Box City State Zip Family Medical History Do you have a family history of any of the following: Sudden death (before 55) Cancer Blood Diseases Diabetes Epilepsy Heart Diseases Hemophilia High Blood Pressure Stroke Drug/ Alcohol Dependency Medical Health History Have you ever had or currently have any of the following: Abnormal Bleeding Allergies (please list) Anemia/ Sickle Cell Trait Asthma/ Bronchitis Blood Clots Cancer/ Tumor/ Cyst Color Blind Contact Lenses/ Glasses Dental Injury Diabetes Epilepsy/ Seizures Eye Injury Frequent Headaches Frequent Respiratory Infect. Genetic Disorders Hearing Defect/ Loss Heart Condition/ Murmur Heat Illness Hepatitis Hernia High Blood Pressure 1

2 Kidney Disease/Condition Mononucleosis Muscular Disease Pleurisy Pneumonia Shortness of Breath Stomach Ulcer Unusual Fatique Urinary Infection Calcium Deposits (list) Current Medications Taken On Regular Basis (Todays Date) Medication Dosage/ Frequency Reason Orthopaedic History/ Exam Have you ever had any of the following conditions: Head Concussion Neck Stingers Back Fracture Disk Injury Chest Abdomen Strain Shoulders Separation/Dislocation Tendinitis/impingement Arm/ Forearm Strain Elbow 2

3 Bursitis/Tendinitis Wrist Tendinitis Hand/ Fingers Strain/Sprain Pelvis/ Hips Groin Strain Hip Flexor Strain Hip Pointer Quads/ Hamstrings Quad Strain Hamstring Strain Knees Sprained Ligaments Torn Cartilage Knee Cap Dislocation Osgood Schlatter's Bursitis Tendinitis Lower Leg Shin Splints Achilles Injury Stress Fracture Ankle Sprain Instability/ Weakness Feet/ Toes Turf Toe Heel Arch Pain Do you wear any Protective Equipment (Braces, Orthotics, etc )? Please list and explain 3

4 I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. I authorize the release of this physical examination to the EWU Athletic Training Department and Team Physicians. First Year Second Year Signautre: Date: Third Year Fourth Year Fifth Year 4

5 Athlete's Name: Sport(s): General Examination Date Comment Date Comment Date Comment Date Comment Date Comment Height Weight BP Pulse % BF Vision L20/ R20/ L20/ R20/ L20/ R20/ L20/ R20/ L20/ R20/ Corrected L20/ R20/ L20/ R20/ L20/ R20/ L20/ R20/ L20/ R20/ ATC/SAT Physician Examination General Head and Neck Eyes (pupils), ENT Teeth Chest Lungs Heart Abdomen Genitalia (Male Only) Skin and Scalp Reflexes Orthopedic Spine Shoulders Elbow, Hand, Wrist Hips and Thighs Knees Ankles Feet Laboratory Sickle Cell Hemoglobin Normal Abnormal Comments Physical Examination Disposition Approved for Participation If not approved, then list following referral and or recommendation(s): Printed Physician's Name: Physician Signature: Disposition Following Referral/Recommendation(s) Approved for Participation Printed Physician's Name: Physician Signature: 5