Sports Participation Medical Examination Form
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2SPORTS PARTICIPATION MEDICAL EXAMINATION
To the Health Care Provider – Please complete and sign
*Mandated Screening/Test under CT State Law
: _______________Date of Exam: _______________
Name:
_____ Date of Birth
Height:*
Weight:*_______________
General Exam
Normal Abnormal Findings
Blood Pressure:*
Pulse: ________________
Appearance
HCT/HGB:*____________
Skin
Urinalysis:
Protein: Blood:
Glucose:______
Heent
Visual Acuity:*________ Right
Left
Respiratory
Corrected to
Right
Left
Cardiovascular
Hearing:*___________________________________
Arrhythmia:
Gross Dental:*________________________________
Murmur:
Abdomen
Body Fat____________%
Neurological
Cholesterol ___________%
Genitalia (hernia)
Physical Maturity (Tanner Stage) 1 2 3 4 5
Last Tetanus Booster
Date:________
Chronic Disease Assessment*
Last Measles(MMR) Booster
Date:________
Yes No
HBV 1_________2_________3___________
__ __ Asthma:__mild__moderate__severe
Varicella Disease Date_______________OR
__exercise induced__unclassified
Varicella Immunization 1_______2________
__ __ Diabetes__Type I__Type II
TB: IN HIGH RISK GROUP ___YES ___ NO
TB TEST
DATE
RESULTS
__ __ Seizure Disorder
________________________________________________
__ __ Anaphylactic Reaction:__ food __ insect __ latex
__ __ Other: Please specify_______________________
Musculoskeletal Evaluation to include range of motion, strength, flexibility
Normal
Abnormal Findings
Neck
Spine
Postural*
Min. ____Slight____Mod.____Marked____
Shoulders
Arms/Hands
Hips
Thighs
Knees
Ankles
Feet
Comments and Recommendations
Weight loss/gain _________________________Medications ________________________________
Strengthening ___________________________Special Equipment____________________________
Stretching ______________________________Bracing/Taping ______________________________
Conditioning (endurance) ___________________________ Comments_________________________
•
I certify that on this date I have examined this student and that, on the basis of the examination requested by the school
authorities and the student’s medical history as furnished to me, I have found no reason which would make it medically
inadvisable for this student to compete in supervised athletic activities except those listed:
__________________________
____________ ___________________
Signature of Physician, RN, APRN,PA
Telephone
Provider Print or Stamp
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