Preparticipation Physical Evaluation Form Page 3
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3Preparticipation Physical Evaluation
CLEARANCE FORM
Name______________________________________Sex__________Age________Date of birth___________________
Cleared without restriction
Cleared, with recommendations for further evaluation or treatment for:___________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Not Cleared for
All sports
Certain sports: ________________________ Reason:__________________
Recommendations:_________________________________________________________________________________
________________________________________________________________________________________________
EMERGENCY INFORMATION
Allergies ________________________________________________________________________________________
Other Information _________________________________________________________________________________
Name of physician (print/type) ____________________________________________________Date _______________
Address ________________________________________________________________Phone ____________________
Signature of physician _____________________________________________________________________, MD or DO
c
2004 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.
Preparticipation Physical Evaluation
CLEARANCE FORM
Name______________________________________Sex__________Age________Date of birth___________________
Cleared without restriction
Cleared, with recommendations for further evaluation or treatment for:___________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Not Cleared for
All sports
Certain sports: ________________________ Reason:__________________
Recommendations:_________________________________________________________________________________
________________________________________________________________________________________________
EMERGENCY INFORMATION
Allergies ________________________________________________________________________________________
Other Information _________________________________________________________________________________
Name of physician (print/type) ____________________________________________________Date _______________
Address ________________________________________________________________Phone ____________________
Signature of physician _____________________________________________________________________, MD or DO
c
2004 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.
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