AT Program Student Physical Form
C. AT Program Student Physical Athletic Training Handbook 28 ATHLETIC TRAINING STUDENT PHYSICAL Name: __________________________________________ Date: _____________________ SS #:____________________________________ Date of Birth _____________________ As part of the requirements for admission into the Athletic Training Program, it must be documented that the student is physically and mentally qualified to participate in the expected athletic training academic and clinical requirements. The athletic training student must have sufficient postural and neuromuscular control, sensory function, and coordination to perform appropriate physical examinations using accepted techniques; and accurately, safely and efficiently use equipment and materials during the assessment and treatment of patients. Examples of the type of physical demands that athletic students must be able to perform include: ● Transporting injured athletes off of playing surface ● Carrying heavy objects such as water cooler and medical kits ● Completing evaluation and assessment techniques to all body joints ● Completing taping and bandaging procedures in a reasonable amount of time ● Getting to injured players in a variety of playing conditions in a reasonable amount of time to care for emergency situations ● Ability to perform first aid and CPR care ● Demonstrating proper lifting and rehabilitation techniques The signature below confirms that Cumberland University team physician has examined the athletic training student and assessed his/her ability to perform the duties required to complete the CAATE Educational Competencies and Clinical Proficiencies based on current written technical standards. Pass__________ Pass with conditions_____________________________ Fail__________ Reason________________________________________ _________________________________________ ____________________ Signature of Team Physician Date Athletic Training Handbook 29 Section Complete: N = Normal F= Flag for additional review ____ Urinalysis ____ Eye Exam ____ Height & Weight ____ Medical Exam ____ Blood Pressure & Pulse ____ Orthopedic Exam Urinalysis (60 second dip) Protein ________ Specific Gravity ________ Leukocytes _______ pH ________ Ketones ________ Blood _______ Glucose ________ Examiner: _____________________ Height/Weight Height: _______ feet ________ inches Weight ________ lbs. Examiner: _____________________ Blood Pressure/Pulse BP 1: ____/____ BP 2: _____/_____ BP 3: _____/_____ Pulse 1: ____ bpm Pulse 2: ____ bpm Pulse 3: ____ bpm Examiner: ____________________ Snellen Eye Examination Right Eye Left Eye With Glasses/Contacts 20/____ 20/____ Without Glasses/Contacts 20/____ 20/____ Athlete wears contacts ____ Athlete wears safety goggles ____ Athlete wears glasses ____ Comments: _______________________________________________________________ _____________________________________________________________________________ Examiner’s Signature: ________________________ Date: __________ Cumberland University Pre-Participation Physical Ex Athletic Training Handbook 30 Medical Examination Circle One Comments Head Normal Abnormal Eyes Normal Abnormal Ears Normal Abnormal Nose Normal Abnormal Throat Normal Abnormal Lungs Normal Abnormal Heart Normal Abnormal Abdomen Normal Abnormal Genitalia Normal Abnormal Extremities Normal Abnormal Neuro/reflex Normal Abnormal Skin Normal Abnormal Comments: _______________________________________________________________ _____________________________________________________________________________ Physician’s Signature: _________________________ Date: ___________ Orthopedic Examination Circle One Comments Athletic Training Handbook 31 Neck Normal Abnormal Spine Normal Abnormal Low Back Normal Abnormal Shoulder Normal Abnormal Elbow Normal Abnormal Wrist/Hand Normal Abnormal Hip Normal Abnormal Knee Normal Abnormal Ankle Normal Abnormal Feet Normal Abnormal Comments: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Physician’s/ATC Signature: _______________________ Date: ___________