History Form - Preparticipation Physical Evaluation (Page 2 of 2) in pdf

REPARTICIPATION

HYSICAL

VALUATION

PHYSICAL EXAMINATION FORM

Name _____________________________________________________________________________________________

Date of Birth ___________________

EXAMINATION

 Male

 Female

Height

Weight

Corrected  Yes  No

(

)

Pulse

Vision R 20/

L20/

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

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

 Location of point of maximal impulse (PMI)

Pulses

 Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)

Skin

 HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

 Duck-walk, single leg hop

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

Consider GU exam if in private setting. Having third party present is recommended.

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

 Cleared for all sports without restriction

 Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________

_____________________________________________________________________________________________________________________________________

 Not cleared

 Pending further evaluation

 For any sports

 For certain sports

___________________________________________________________________________________________________________________________

Reason

___________________________________________________________________________________________________________________________

Recommendations

___________________________________________________________________________________________________________________________

I have examined the above-named student and completed the participation physical evaluation.

The athlete does not present apparent clinical

contraindications to practice and participate in the sport(s) as outlined above. If conditions arise after the athlete has been cleared for participation, the

physician may rescind the clearance until the problem is resolve and the potential consequences are completely explained to the athlete (and

parents/guardians).

Name of physician (print/type) ________________________________________________________________________

Date __________________________

Address __________________________________________________________________________________________

Phone _________________________

Signature of physician _______________________________________________________________________________________________________, MD or DO