Upper classmen, please note: 

If physical form is already on file @ PA, please indicate with a “check.”  ________________

Incoming freshmen and/ or transfers must show evidence of a physical on or after March 1, 2007.

PEMBROKE ACADEMY

PHYSICAL EXAMINATION FOR SPORTS PARTICIPATION

NAME __________________________________ DOB ______________ SEX:  M    F

MEDICAL ISSUES _____________________________________________________

ALLERGIES ____________________________  MEDICATIONS _______________

Please address the following, as this student will be participating in a strenuous program

of sports and related physical activity.  Please note IMMUNIZATIONS.

DATE___________   AGE _______  HT _______  WT________  VISION__________

BP __________    P___________

DATE OF LAST TETUNAS  ______________

DATE(S) OF HEPATITIS SERIES ____________ , ______________, ____________

SKIN:    Acne                  Herpes                     Athletes Foot

EYES/EARS:  Pupils                 Conjunctiva                     Discharge

RESPIRATORY:   Wheezing             Rales            Resp effort                Breath sounds

CARDIAC:   Murmur                    Rate                   Rhythm

MUSCULOSKELETAL:   Scoli              Knees                  Weakness                  Balance

OTHER:________________________________________________________________

RECOMMENDATIONS:              (   )  FULL PARTICIPATION

CHECK ONE AND SIGN             (   )  LIMITED/RESTRICTED PARTICIPATION:  

                                                                _____________________________________

                                                                _____________________________________

PHYSICIANS SIGNATURE                                              DATE

________________________________                           ___________________