Athletic Pre-Participation - Physical Examination Form Page 2
ADVERTISEMENT
1
2PHYSICAL EXAMINATION RECORD (To be completed by a licensed 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 __________ Vision R 20/__________ L 20/ __________
NORMAL
ABNORMAL FINDINGS
INITIALS
1. Appearance (esp. Marfan’s) __________________________________________________________________________________
2. Eyes/Ears/Nose/Throat
__________________________________________________________________________________
3. Mouth & Teeth
__________________________________________________________________________________
4. Neck
__________________________________________________________________________________
5. Lymph Nodes
__________________________________________________________________________________
6. Heart (Standing & Lying) __________________________________________________________________________________
7. Pulses (esp. femoral)
__________________________________________________________________________________
8. Chest & Lungs
__________________________________________________________________________________
9. Abdomen
__________________________________________________________________________________
10. Skin
__________________________________________________________________________________
11. Genitals – Hernia
__________________________________________________________________________________
12. Musculoskeletal – ROM,
strength, etc. (See questions 20-27) ______________________________________________________________________________
13. Neurological
__________________________________________________________________________________
Comments regarding abnormal findings: ________________________________________________________________________
____________________________________________________________________________________________________________
ATHLETIC PARTICIPATION RECOMMENDATIONS:
______ Full & Unlimited Participation
______ Limited Participation – May NOT participate in the following (checked):
______ Baseball ______ Basketball ______ Cross Country ______ Football ______ Golf ______ Soccer
______ Softball
______ Swimming ______ Tennis ______ Track ______ Volleyball ______ Wrestling
______ Clearance Pending Documented Follow up of _____________________________________________________________
______ NOT CLEARED FOR ATHLETIC PARTICIPATION
___________________________________________________________________________
______________________________
Licensed Professional’s Name (Printed)
Date
___________________________________________________________________________
______________________________
Licensed Professional’s Signature
Parent’s or Guardian’s Permission and Release (Sign after the physical examination has been completed.)
I hereby 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, athletic
trainer, or other qualified personnel to give first aid treatment to my son or daughter at an athletic event in case of injury.
___________________________________________________
___________________________________________________
Typed or printed Name of Parent or Guardian
Signature of Parent or 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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical