Preparticipation Physical Evaluation: Medical History Form (Page 2 of 5) in pdf

■■■GateWay Geckos Preparticipation Physical Evaluation■■■

PHYSICAL EXAMINATION FORM

Name

Date of birth

EKG (Current EKG REQUIRED) Attach EKG Result Sheet & Clearance

ABNORMAL FINDINGS

EKG Date

NORMAL

Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

 Male

 Female

Height

Weight

 Y

 N

(

)

Pulse

Vision R 20/

L 20/

Corrected

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

• Pupils equal

• Hearing

Lymph nodes

Heart

• Murmurs (auscultation standing, supine, +/- Valsalva)

• Location of point of maximal impulse (PMI)

Pulses

• Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)

Skin

• HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

• Duck-walk, single leg hop

Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.

Consider GU exam if in private setting. Having third party present is recommended.

Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

Not cleared

Pending further evaluation

For any sports

For certain sports

Reason

Recommendations

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice

and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the athlete/

parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential

consequences are completely explained to the athlete (and parents/guardians).

Name of physician

(print/type)

Date

Address

Phone

Signature of physician

______,MD, DO, PA-C, NP