Lausd - Preparticipation Physical Evaluation Form Page 2

Physical Examination Form

The section below is to be completed by physician or staff after history and consent forms are completed.

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Student's Name: _____________________________________________________________________________________________ DOB:______________________

Height: _________ Weight: _________ %BMI (optional): _________ Pulse: _________ BP _________/ _________, (_________/ _________, _________/ _________)

Vision R 20/ __________ L 20/ __________

Corrected:

Y

N

Pupils: Equal __________ Unequal __________

EMERGENCY INFORMATION

Allergies: __________________________________________________________________________________________________________________________________

Other Information: ___________________________________________________________________________________________________________________________

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 ¹

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

Location of point of maximal impulse (PMI)

Lungs

Abdomen

Genitourinary (males only) ²

Skin

HSV, lesions suggestive of MRSA, tinea corporis

Neurologic ³

MUSCULOSKELETAL

Neck

Back

Shoulder/ Arm

Elbow/ Forearm

Wrist/ Hand/ Fingers

Hip/ Thigh

Knee

Leg/ Ankle

Foot/ Toes

Functional

Duck walk, single leg hop

¹ Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam

² Consider GU exam if in private setting. Having 3rd party present is recommended.

³ Consider cognitive evaluation or baseline neuropsychiatric setting if a history of significant concussion.

Clearance

□

Cleared for all sports without restriction

□

Cleared for all sports without restriction with recommendations for further evaluation or treatment for: ______________________________________________________

□

Not cleared

□

Pending further evaluatiion

□

For any sports

□

For certain sports______________________________________________________________________________________________________________

Reason/Recommendations_____________________________________________________________________________________________________________________

I have evaluated the above named student and completed the pre-participation physical evaluation. The athlete does not present apparent contraindications to practice, tryout 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 parent. If conditions arise after the athlete has been cleared for participation, t

h

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/ Provider: (print/ type/ stamp) _________________________________________________________ (MD, DO, NP or PA)

Date: _________________

Address: ______________________________________________________________________________________________________ Phone: ______________________

Signature of Physician/ Provider: ________________________________________________________________________________________________________________

Modified from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports

Medicine, and American Osteopathic Academy of Sports Medicine, 2010.