Alabama Preparticipation Physical Evaluation Form Page 2
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2Rule 1, Sec. 14 — In order for a student to be eligible for interscholastic athletics, there must be
Preparticipation Physical Evaluation
on file in the Superintendent’s or Principal’s office a current physician’s statement certifying that
the student has passed a physical exam, and that in the opinion of the examining physician (M.D.
or D.O.) the student is fully able to participate in interscholastic athletics (Grade s 7‐12). The
AHSAA Physicians Certificate (Form 5) must be used. A physical exam will satisfy the
requirement for one calendar year from the date of the exam.
Physical Examination
Height ____________ Weight _____________ BP _____ / _____ Pulse ____________
Vision R 20 / ____ L 20 / ____ Corrected: Y
N
Normal
Abnormal Findings
Cardiovascular
Pulses
Heart
Lungs
Skin
E.N.T.
Abdominal
Genitalia (males)
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Other
Clearance:
A. Cleared
B. Cleared after completing evaluation/rehabilitation for: _______________________________________
C. Not cleared for:
Collision
Contact
Noncontact
____ Strenuous
____ Moderately strenuous
____ Nonstrenuous
Due to: ____________________________________________________________________________________________
Recommendation: _________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Name of physician ________________________________________________________________ Date ____________________
Address ________________________________________________________________________ Phone___________________
.
Signature of physician _____________________________________________________________, M.D. or D.O.
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Parent category: Medical