Florida Atlantic University Physical Examination Demographics



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Florida Atlantic University

Physical Examination
Demographics:

Name:________________________________ SS# _____-___-_____ Sport________

Birth Date / Age ___________/____________
Physical:

Height__________ Weight__________ Body Fat %__________ Pulse_____ BP___/___


General Medical Examination:

HE _____________________________ ABD _______________________________

ENT _____________________________ GU _______________________________

Neck _____________________________ Hernia _______________________________

Chest _____________________________ Neuro. _______________________________

CV _____________________________ Skin _______________________________

Remarks: ________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________
Orthopedic Examination:

Cervical / Thoracic Spine:___________________ Lumbar Spine:__________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

Shoulder: ________________________________ Knee: _________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

Elbow: __________________________________ Hip: __________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

Wrist / Hand: _____________________________ Ankle / Foot: ___________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

________________________________________ ______________________________________

Comments: ______________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________


Circle One: The Athlete (may) (may not) participate in Florida Atlantic University athletics.
__________________________________/_____ _____________________________/________

Internal Medicine Physician’s Signature / Date Orthopaedic Physician Signature / Date

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