1. No category

A H S A A P h y s i c i a n s C e r t i f i c a t e ( F o r m 5 ) m u s t b e u s e d . A physical exam will satisfy the
requirement for one calendar year from the date of the exam.
Physical Examination
Heiqfit
Weight
Vision R 20 /
L 20 /
Corrected:
Y
LU
H
Cardiovascular
-J
Pulses
/
Pulse
N
Normal
Q
2
BP
Abnormal Findings
Heart
Lungs
Skin
E.NT.
Abdominal
LU
1-
LU
_i
CL
Genitalia (males)
O
O
Musculoskeletal
Neck
Stioulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Other
Clearance:
A. Cleared
-
B. Cleared after completing evaluation/rehabilitation for:
C. Not cleared for:
•
Collision
•
•
Contact
Noncontact
Strenuous
Moderately strenuous
Nonstrenuous
Due to:
Recommendation:
Name of physician
Date
Address
Phone
Signature of physician
[
, M.D. or D.O.
•1