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Mandatory for all incoming students to have a physical the year they are entering college. Sports physicals are to be complete within 6 months prior to the sport that the student will be playing. Student athletes should view athletic webpage for additional medical requirements (Sickle Cell Trait). Biddeford Student Health Center 11 Hills Beach Road Biddeford, ME 04005 Tel: (207) 602-2358 Fax: (207) 602-5904 Portland Student Health Center 716 Stevens Ave Portland, ME 04103 Tel: (207) 221-4242 Fax: (207) 523-1913 Physical Form Name: ____________________________________________________________________ DOB: __________________________ Street: _________________________________________City:_________________________ State: _______ Zip: ______________ Cell: _____________________________________________ Home: ____________________________________________________ Height: ___________ Weight: _____________ B/P:______________ Temp:______________ Vision: R_____/_____L_____/_____ Urinalysis: Sugar: ______________ Protein: ______________Tobacco Use: ______________ Allergies: ______________________________________ Medications and Dosing: Diagnosis: 1._________________________ 2._________________________ 1.___________________________ 2.__________________________ 3._________________________ 4._________________________ 3.___________________________ 4.__________________________ 5._________________________ 6._________________________ 5.___________________________ 6.__________________________ Normal Abnormal Clinical Evaluation Describe abnormalities Ears Eyes Nose, sinuses Mouth, throat, dental Head, scalp, face, neck Lungs & chest Breasts Heart Vascular system Abdomen & viscera (include hernia) Anus & rectum Metabolic/endocrine GU Male (testicles) GU Female (pelvic/PAP, if indicated) Upper extremities (ROM, strength) Lower extremities (ROM, strength) Musculoskeletal system (spine) Feet Skin Neuropsychiatric Do you feel this student is in good health to participate in athletics/ intramurals and clinical activities? YES NO If no what are the recommendations: _____________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _____________________________________ ___________________ _____________________ Signature of Provider Date Telephone #

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  • Mandatory for all incoming students to have a physical the year they are entering college.

    Sports physicals are to be complete within 6 months prior to the sport that the student will be playing.

    Student athletes should view athletic webpage for additional medical requirements (Sickle Cell Trait).

    Biddeford Student Health Center 11 Hills Beach Road

    Biddeford, ME 04005 Tel: (207) 602-2358 Fax: (207) 602-5904

    Portland Student Health Center 716 Stevens Ave

    Portland, ME 04103 Tel: (207) 221-4242 Fax: (207) 523-1913

    Physical Form

    Name: ____________________________________________________________________ DOB: __________________________

    Street: _________________________________________City:_________________________ State: _______ Zip: ______________

    Cell: _____________________________________________ Home: ____________________________________________________

    Height: ___________ Weight: _____________ B/P:______________ Temp:______________ Vision: R_____/_____L_____/_____ Urinalysis: Sugar: ______________ Protein: ______________Tobacco Use: ______________ Allergies: ______________________________________

    Medications and Dosing: Diagnosis:

    1._________________________ 2._________________________ 1.___________________________ 2.__________________________

    3._________________________ 4._________________________ 3.___________________________ 4.__________________________

    5._________________________ 6._________________________ 5.___________________________ 6.__________________________

    Normal Abnormal Clinical Evaluation Describe abnormalities

    Ears

    Eyes

    Nose, sinuses

    Mouth, throat, dental

    Head, scalp, face, neck

    Lungs & chest

    Breasts

    Heart

    Vascular system

    Abdomen & viscera (include hernia)

    Anus & rectum

    Metabolic/endocrine

    GU Male (testicles)

    GU Female (pelvic/PAP, if indicated)

    Upper extremities (ROM, strength)

    Lower extremities (ROM, strength)

    Musculoskeletal system (spine)

    Feet

    Skin

    Neuropsychiatric

    Do you feel this student is in good health to participate in athletics/ intramurals and clinical activities? YES NO

    If no what are the recommendations: _____________________________________________________________________________

    ___________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________

    _____________________________________ ___________________ _____________________

    Signature of Provider Date Telephone #


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