Athletic Pre-Participation Physical Examination Form - New Jersey Department Of Education Page 4
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4Most recent immunizations/Dates:
Medications currently being used:
Additional Observations:
General Diagnosis: ____________________________________________________________________________
Recommendations: ___________________________________________________________________________
CLEARANCES
A.
Student MAY participate in the following sports: (
)
CHECK ALL THAT APPLY
___ CONTACT/COLLISION
___ NON-CONTACT/STRENUOUS
___ LIMITED CONTACT
___ NON-CONTACT/NON-STRENUOUS
SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT
Contact/Collision
Limited Contact
Non-Contact
Strenuous
Non-strenuous
Field Hockey
Baseball
Discus
Bowling
Football
Basketball
Javelin
Golf
Ice Hockey
Cheerleading
Shot put
Lacrosse
Diving
Rowing
Soccer
Fencing
Running/Cross Country
Wrestling
Field
Strength Training
High Jump
Swimming
Pole vault
Tennis
Gymnastics
Track
Skiing
Softball
Volleyball
B.
Student MAY participate in following sport(s) ONLY AFTER completing evaluation/rehabilitation: (C
)
HECK ALL THE APPLY
___ CONTACT/COLLISION
___ NON-CONTACT/STRENUOUS
___ LIMITED CONTACT
___ NON-CONTACT/NON-STRENUOUS
Please specify each condition requiring clearance before participating in a sport in the classification checked above:
________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Conditions requiring clearance before sports participation include, but are not limited to: Atlantoaxial instability; Bleeding disorder;
Hypertension;Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating
disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; History of repeated concussion; Organ
transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.
Physician’s/Provider’s Stamp:
EXAMINED BY:
Family Physician/Provider_____
School Physician_____
____MD ____DO____NP____PA
Physician’s/Provider’s Signature: __________________________________________________ Date: _____________
NOTE TO SCHOOL PHYSICIANS: Pursuant to N.J.A.C. 6A:16-2.2, the school physician shall provide written notification to the
parent/legal guardian stating approval or disapproval of the student’s participation in athletics based on this medical report. Please attach
this form to the notification letter and ensure that this report is made part of the student’s permanent health record.
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