Iowa Athletic Pre-Participation Physical Examination Form Page 2
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3PHYSICAL EXAMINATION
RECORD
(To be completed by a licensed medical professional as designated in Article VII
36.14(1). This evaluation is only to determine readiness for sports participation. It should NOT be used as a substitute for
regular health maintenance examinations.
Athlete’s Name ___________________________________________________________ Height _________ Weight ___________
Pulse _________
Blood Pressure ______/_____ (Repeat, if abnormal ______/______)
Vision
R 20/_________ L 20/___________
NORMAL
ABNORMAL FINDINGS
INITIALS
1. Appearance (esp. Marfan’s ) ______________________________________________________________________________
2. Eyes/Ears/Nose/Throat
______________________________________________________________________________
3. Pupil Size (Equal/Unequal) ______________________________________________________________________________
4. Mouth & Teeth
______________________________________________________________________________
5. Neck
______________________________________________________________________________
6. Lymph Nodes
______________________________________________________________________________
7. Heart (Standing & Lying)
______________________________________________________________________________
8. Pulses (esp. femoral)
______________________________________________________________________________
9. Chest & Lungs
______________________________________________________________________________
10. Abdomen
______________________________________________________________________________
11. Skin
______________________________________________________________________________
12. Genitals - Hernia
______________________________________________________________________________
13. Musculoskeletal -
ROM,
______________________________________________________________________________
strength, etc. (See questions 24-31)
14. Neurological
______________________________________________________________________________
Comments regarding abnormal findings: ____________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
LICENSED MEDICAL PROFESSIONAL’S ATHLETIC PARTICIPATION RECOMMENDATIONS
FULL & UNLIMITED PARTICIPATION
_____
LIMITED PARTICIPATION
_____
- May NOT participate in the following (checked):
_____ Baseball _____ Basketball _____ Bowling _____ Cross Country _____ Football _____ Golf _____ Soccer
_____ Softball
_____ Swimming _____ Tennis
_____ Track
_____ Volleyball
_____ Wrestling
CLEARANCE PENDING DOCUMENTED FOLLOW UP OF
_____
______________________________________________
NOT CLEARED FOR ATHLETIC PARTICIPATION DUE TO_________________________________
_____
___________________________________________________________________________
___________________________
Licensed Medical Professional’s Name (Printed)
Date of PPE
__________________________________________________________________________
___________________________
Licensed Medical Professional’s Signature
Phone
PARENT’S OR GUARDIAN’S PERMISSION AND RELEASE
I hereby verify the accuracy of the information on the opposite side of this form and give my consent for the above named student
to engage in approved athletic activities as a representative of his/her school, except those activities indicated above by the
licensed professional. I also give my permission for the team’s physician, certified athletic trainer, or other qualified personnel to
give first aid treatment to my son or daughter at an athletic event in case of injury.
________________________________________________
_____________________________________________________
Name of Parent or Guardian (Printed)
Signature of Parent of Guardian
_____________________________________________________________________
________________________________
Address (Street/PO Box, City, State, Zip)
Phone Number
This form has been developed with the assistance of the Committee on Sports Medicine of the Iowa Medical Society and has been approved for
use by the Iowa Department of Education, Iowa High School Athletic Association, and Iowa Girls High School Athletic Union. Schools are
encouraged NOT to change this form from its published format. Additional school forms can be attached to this form.
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