Martial Arts Medical Examination Form for Black Belts - All Stars Self ...

PRE GRADING PARTICIPATIONPHYSICAL EVALUATION & PHYSICAL EXAMINATIONFORMStudent's Name ________________________________ Sex _______ Age _______ Date of Birth ________________Height ________________ Weight__________________ % Body fat (optional) ___________________Pulse ________________________ BP______/______ (______/______, ______/______)brachial blood pressure while sittingVision R 20/______ L 20/___ Corrected: Y N Pupils: Equal UnequalAs a minimum requirement, this Physical Examination Form must be completed prior to attempting a martial arts typeor similar grading.MEDICALAppearanceEyes/Ears/Nose/ThroatLymph NodesHeart-Auscultation of the heart inthe supine position.Heart-Auscultation of the heart inthe standing position.Heart-Lower extremity pulsesPulsesLungsAbdomenGenitalia (males only)SkinMarfan’s stigmata (arachnodactyly,pectus excavatum, jointhypermobility, scoliosis)NORMAL ABNORMAL FINDINGS INITIALS*MUSCULOSKELETALNeckBackShoulder/ArmElbow/ForearmWrist/HandHip/ThighKneeLeg/AnkleFoot*station-based examination only

CLEARANCE Cleared Cleared after completing evaluation/rehabilitation for ;____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Not cleared for:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reason:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The following information must be filled in and signed by either a Physician or Doctor of Medicine. Examination formssigned by any other health care practitioner, will not be accepted.Name of Examiner __________________________________________ Date of Examination:__________________Address:______________________________________________________________________________________Phone Number:_____________________________ Signature:___________________________________________Additional Comments____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Must be completed before a student participates in any grading, (both in-season and out-of-season). This form must be handed into the centre in which grading is to be attempted no later than on the morning of grading. This form must be no olderthan 7 days old or you will be required to obtain another medical examination certificate on the day time permitted.