***This form must be completed by your child’s physician.*** 

Name:
Date of Birth:
Address:
Phone:
Vision - without glasses	R	L	
Vision w / correction	R	L	
Vision - Near Point	R	L	
Hearing	R	L	

Check if up to date:  YES Diphtheria
Tetanus
Polio
MMR
HepB
Varicella
Rib
	Significant Medical/Surgical History:
NO
Check here if entire exam normal
Height:
Weight:
B.P.:
General Appearance	Normal	Abnormal	Comments	
Skin				
Head				
Eyes				
Ears				
Nose, Throat & Teeth				
Lymph Nodes/Thyroid				
Lungs				
Heart				
Abdomen				
Musculoskeletal & Motor				
Neurological				
Neurodevelopmental Behavior				
Medication (List All): _None Name:
Dosage/Time:
Dosage/Time:
Name:
NORTH BUFFALO RAMS 
FOOTBALL AND CHEERLEADING
 HEALTH APPRAISAL FORM

D Cheerleading: Limited Contact/ Lifting/ Balance/ Aerobics

D Non-contact: Check only if this is a restriction.

D Known or suspected disability:
Please explain:
D Restrictions:
Please explain:
D Protective equipment required:	D Athletic cup	D Glasses/eyewear	
	D Other 
This exam is to comply with medical requirements necessary to participate in North Buffalo Rams Football & Cheerleading. It is valid for one year through the last day of the month listed below, with the exception of any illness or injury lasting more than five days that will negate this certification.

Date:
Phone:
Provider’s Name:
Provider's Signature: