Sports Qualifying Physical Examination Clearance Form printable pdf download

Revised 4/12/17

Page 1 of 4

COPY this Clearance Form for the student to return to the school. KEEP the complete document in the student’s medical record.

2017-2018 SPORTS QUALIFYING PHYSICAL EXAMINATION CLEARANCE FORM

Minnesota State High School League

Student Name: _________________________________

Birth Date: __________

Age: ____

Gender: M / F

Address: ______________________________________________________________________________________

Home Telephone: ______ - ______ - ____________ Mobile Telephone _____ - _____ - ____________

School: ______________________________

Grade: ____

Sports: ___________________________________

I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check Only One Box)



 (1) Participate in all school interscholastic activities without restrictions.



 (2) Participate in any activity not crossed out below.

Sport Classification Based on Contact

Sport Classification Based on Intensity & Strenuousness

Collision Contact

Limited Contact

Non-contact Sports

Sports

Field Events:

❖

Discus

Alpine Skiing*†

❖

Shot Put

Wrestling*

Basketball

Baseball

Badminton

Gymnastics*†

Cheerleading

Field Events:

Bowling

❖ High Jump

Diving

Cross Country Running

❖ Pole Vault

Football

Dance Team

Basketball*

Football*

Ice Hockey*

Gymnastics

Floor Hockey

Field Events:

Lacrosse*

❖ Discus

Ice Hockey

Nordic Skiing

Diving*†

❖

High Jump

Nordic Skiing — Freestyle

❖

Pole Vault*†

❖ Shot Put

Lacrosse

Softball

Track — Middle Distance

Synchronized Swimming†

Swimming†

Alpine Skiing

Volleyball

Golf

Track — Sprints

Soccer

Swimming

Badminton

Wrestling

Tennis

Baseball*

Cross Country Running

Track

Cheerleading

Bowling

Nordic Skiing — Classical

Floor Hockey



Golf

Soccer*

Softball*

Tennis

Volleyball



Track — Long Distance

 (3) Requires further evaluation before a final

recommendation can be made.

A. Low

B. Moderate

C. High

(<40% Max O

)

(40-70% Max O

)

(>70% Max O

)

Additional recommendations for the school or

Increasing Dynamic Component     

parents: _______________________________

______________________________________

Sport Classification Based on Intensity & Strenuousness: This classification is based on peak static and

dynamic components achieved during competition. It should be noted, however, that higher values may be reached

______________________________________

during training. The increasing dynamic component is defined in terms of the estimated percent of maximal oxygen



 (4) Not cleared for: All Sports

uptake (MaxO

) achieved and results in an increasing cardiac output. The increasing static component is related to

the estimated percent of maximal voluntary contraction (MVC) reached and results in an increasing blood pressure



Specific Sports ________

load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in lightest shading

and the highest in darkest shading. The graduated shading in between depicts low moderate, moderate, and high

______________________________________

moderate total cardiovascular demands. *Danger of bodily collision. †Increased risk if syncope occurs. Reprinted

Reason: _______________________________

with permission from: Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recommendations for competitive

athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2005; 45(8):1317–1375.

______________________________________

I have examined the above named student and completed the Sports Qualifying Physical Exam as required by the Minnesota State High School League.

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 parents.

Attending Physician Signature ______________________________________

Date of Exam ___________________

Print Physician Name: _____________________________

Office/Clinic Name ________________________________

Address: ________________________________________

City, State, Zip Code ________________________________________________________________________________

Office Telephone: _____ - _____ - ________

E-Mail Address: _____________________________________________

IMMUNIZATIONS

[Tdap; meningococcal (MCV4, 1-2 doses); HPV (3 doses); MMR (2 doses); hep B (3 doses); hep A (2 doses); varicella (2 doses

or history of disease); polio (3-4 doses); influenza (annual)]

 Up-to-date (see attached school documentation)  Not reviewed at this visit

IMMUNIZATIONS GIVEN TODAY: _____________________________________________________________________

EMERGENCY INFORMATION

Allergies _________________________________________________________________________________________

Other Information __________________________________________________________________________________

Emergency Contact: ____________________________________________ Relationship _________________________

Telephone: (H) _____ - _____ - ________ (W) _____ - _____ - ________ (C) _____ - _____ - ________

Personal Physician ____________________________________

Office Telephone _____ - _____ - ________

This form is valid for 3 calendar years from above date with a normal Annual Health Questionnaire.

 [Year 2 Normal]

 [Year 3 Normal]

FOR SCHOOL ADMINISTRATION USE:

Reference: Preparticipation Physical Evaluation (4th Edition): AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM; 2010.

Sports Qualifying Physical Examination Clearance Form

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