GWINNETT LACROSSE LEAGUE PHYSICAL EXAMINATION FORM Year: 2016 Player's Legal Name ______________________________________ Date of Birth _________________ Name must match name on report card - no nicknames or shortened names

MEDICAL HISTORY (to be completed by parent - prior to physical) Yes

No

Allergies Asthma Bone or Joint Disease Concussion history Contact Lenses/Glasses Diabetes

Yes

No

Epilepsy/Seizures Hearing Disorder Heart Disease Lung Disease Poliomyelitis Tetanus Booster may be given

Explain "Yes" answers above _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct

Parent Signature ________________________________________________

Date __________________

EXAMINATION (to be completed by MD, DO, PA, or NP ONLY) Height Pulse before exercise Normal

Weight Pulse after exercise Abnormal Findings

General Condition Abdomen Ears Eyes Heart Lungs

Male

Female

B/P Normal

Abnormal Findings

Lymph Nodes Neck Neurologic Shoulder/Arm Skin Spine

Cleared for Sports without Restriction Cleared for Sports without Restriction with recommendations for further evaluation or treatment for __________________________________________________________________________________________ Not Cleared for Sports Provide printed name, address and phone number of Medical Provider in the box below Office stamp preferred.

Provider Signature ________________________________________________

(MD, DO, PA, or NP only)

Date of Exam __________________