Get Brown University Supplemental Athletic Physical Form

BROWN UNIVERSITY Return to Health Services Box 1928 Providence Rhode Island 02912 401-863-3953 SUPPLEMENTAL ATHLETIC PHYSICAL FORM To be completed by your medical provider Examination within the past 6 months and completion of this form is required if the student expects to enter intercollegiate athletics. Failure to submit a completed form will result in delayed team participation* In compliance with NCAA regulations we cannot clear a student to practice or participate in any team sport without a completed history and physical on file. Name Date of Birth Banner I. D. B00 In which sport s do you expect to compete COMPLETION OF ALL SECTIONS IS REQUIRED Visual Acuity Urine Dip Negative Height PHYSICAL EXAM Date of Exam HEENT include fundi Lungs Chest Heart including murmurs Abdomen Hernia / Testicles Extremities / Pulses document femoral Musculoskeletal Skin Lymph Nodes / Neck / Thyroid Neurologic including DTR s Breast Exam Gross Hearing Screen ORTHOPEDIC EXAMINATION Provider Instructions Check for physical stigmata of Marfan s Look at ceiling floor over both shoulders touch ears to shoulders Shrug shoulders examiner resists Abduct shoulders 90 degrees examiner resists at 90 degrees Full external rotation of arms Flex and extend elbows Arms at sides elbows 90 degrees Flexed pronate and supinate wrists Spread fingers make fist Duck walk four steps away from examiner with buttocks on heels Back to examiner Knees straight touch toes Raise up on toes raise heels R20 / L20 / Abnormal Pulse Normal corrected uncorrected athletes must have 20/40 corrected Positive Findings Respiration Blood Pressure Explanation of Abnormal Finding For continuity of care we request that medical records be forwarded for chronic serious medical conditions. Observation Very tall long limbs fingers/hands pectus deformities kyphoscoliosis high arched palate arm span exceeds height upper body short compared to lower Acromioclavicular joints general habitus cervical spine motion Describe Abnormals Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand or finger motion and deformities Hip knee ankle motion Shoulder symmetry scoliosis Scoliosis hip motion hamstring tightness Calf symmetry leg strength PARTICIPATION IN SPORTS Without restrictions Should not participate in sports May participate with the following restrictions Medical or orthopedic problems must be evaluated before participation is allowed Signature of Physician/Medical Provider Date Physician/Medical Provider Name Please Print /Clinic Stamp Address Phone number Fax Number. Failure to submit a completed form will result in delayed team participation* In compliance with NCAA regulations we cannot clear a student to practice or participate in any team sport without a completed history and physical on file. Name Date of Birth Banner I. D. B00 In which sport s do you expect to compete COMPLETION OF ALL SECTIONS IS REQUIRED Visual Acuity Urine Dip Negative Height PHYSICAL EXAM Date of Exam HEENT include fundi Lungs Chest Heart including murmurs Abdomen Hernia / Testicles Extremities / Pulses document femoral Musculoskeletal Skin Lymph Nodes / Neck / Thyroid Neurologic including DTR s Breast Exam Gross Hearing Screen ORTHOPEDIC EXAMINATION Provider Instructions Check for physical stigmata of Marfan s Look at ceiling floor over both shoulders touch ears to shoulders Shrug shoulders examiner resists Abduct shoulders 90 degrees examiner resists at 90 degrees Full external rotation of arms Flex and extend elbows Arms at sides elbows 90 degrees Flexed pronate and supinate wrists Spread fingers make fist Duck walk four steps away from examiner with buttocks on heels Back to examiner Knees straight touch toes Raise up on toes raise heels R20 / L20 / Abnormal Pulse Normal corrected uncorrected athletes must have 20/40 corrected Positive Findings Respiration Blood Pressure Explanation of Abnormal Finding For continuity of care we request that medical records be forwarded for chronic serious medical conditions. .