Rowing Tryout Physical Form
 

James A. Taylor Student Health Service
Division of Student Affairs
The University of North Carolina at Chapel Hill

Physical Form in PDF

ROWING TRY-OUT PHYSICAL

PLEASE PRINT CLEARLY

NAME:_______________________________________________________

HOME PHONE: ________________________________

AGE:___________________ DATE OF BIRTH: ________ / _________ / ___________

ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AS POSSIBLE:YES NO DON'T KNOW ELABORATION OF YES ANSWERS
Has anyone in your family (grandparents, parents, brothers, sisters) died before the age of 50?
Have you ever stopped exercising because you were dizzy or have you ever passed out during exercise?
Have you ever been told you have a heart problem?
Do you ever experience wheezing, difficult breathing or coughing while exercising?
Have you ever broken a bone, dislocated a joint, or had to wear a cast?
List joints:
Have you ever had a concussion, head/neck/back injury, or tingling or numbness in your arms/legs?
Have you ever had a heat related illness (heat stroke, heat exhaustion) or had difficulty exercising in warm/hot weather?
Do you have anything you want to talk to the doctor about?
Do you have a chronic illness or see a doctor regularly for any particular problem?
Are you taking any medications?
List drug(s), dosage, times/day:
Are you allergic to any medications or bee stings?
List medications:
Do you have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc)?
Do you wear contacts or eye glasses?
Do you feel you are over or under weight or are you on a special diet?
Has a doctor ever told you to give up sports or limit your activity because of a health related problem?

I have read and agree with my answering of the above medical history questions.

Patient Signature:______________________ Date:________ / _______ / _______

A. VITAL STATISTICS:
Height: __________ Weight:____________ Blood Pressure: ____________________

B. MUSCULOSKELETAL EXAM:

NORMAL ABNORMAL RECORD LAXITY, WEAKNESS, INSTABILITY, DECREASED ROM, OR POSITIVE TESTS
NECK
SHOULDER
SPINE
HIP
KNEE
ANKLE
FEET
OTHER

C. PHYSICIAN'S EXAM:

NORMAL ABNORMAL COMMENTS
ENT
HEART
LUNGS
ABDOMEN
SKIN
OTHER

D. PHYSICIAN'S ASSESSMENT AND COMMENTS:

E. RECOMMENDATIONS:

1. Cleared_____ 2. Not Cleared: _______ 3. Plan:____________________

F. PHYSICIAN'S SIGNATURE:

Signature:________________________________________ Date: _____ /_____ / _____

Name (print): ___________________________ Phone Number: __________________