Aquinas High School Sports Physical Exam 2772 Sterling Ave, San Bernardino, Ca 92404

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in file.)
Date of Exam ____________________________________________________________________________ Time of Exam _______________

Name ____________________________________________________________________________________ Date of Birth ____________ Sex _______ Age _______ Grade _______ School______________ Sport(s)__________________

Father’s Name: __________________________________ Daytime Phone, Cell Phone: ______________________ Mother’s Name: _________________________________ Daytime Phone, Cell Phone: ______________________ Street Address: ________________________________________________________________________________ City: __________________ State: __________ Zip Code: ____________ Home Phone: _____________________ Alternate Emergency Contact Person: ______________________________ Daytime Phone: __________________ Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc: ___________________________ _____________________________________________________________________________________________ Examination (Physician use ONLY)

Cleared for all sports without restriction
Cleared for all sports with further recommendation for __________________________________________________________

________________________________________________________________________________________________________

Not Cleared
Waiting for Evaluation Any sport(s)

Reason: ___________________________________________________________________________________

             __________________________________________________________________________________________

Recommendation: ________________________________________________________________________________________

________________________________________________________________________________________________________

I have examined the above-named student and completed the pre-participation physical exam. A copy of the physical exam is on record in my office and can be made available to the school at anytime.

Name of Physician (Print/Type): _______________________________________________ Date: ______

Address: _________________________________________________________ Phone: _____________

Signature of Physician: ________________________________________________________, MD or DO

By signing below, I affirm that my son/daughter has completed the physical form necessary for the participation in sports. I am fully aware and recognize that by participating in sports he/she may be become hurt, and or injured.

Parent/Guardian Name: _______________________________________________ Date: _____________

Time of Completion of Exam: __________________________

Parent/Guardian Signature: ______________________________________________ Date: ___________

By signing below, I affirm that I (the athlete) has completed the physical examination necessary to compete in sports. I am fully aware that by participating in sports I can be hurt, or injured.

Athletes Name: ______________________________________________________ Date: ____________

Time of Completion of Exam: ____________________________

Athletes Signature: ___________________________________________________ Date: ____________

Aquinas High School
2772 Sterling Ave, San Bernardino, Ca 92404 "Lux et Veritas"