Preparticipation Physical Evaluation - Florida High School Athletic Association Page 4
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9EL2
Florida High School Athletic Association
Revised 03/10
Preparticipation Physical Evaluation
(Page 2 of 3)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
Part 3. Physical Examination
(to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physi-
cian, licensed physician assistant or certified advanced registered nurse practitioner).
Student’s Name: _____________________________________________________________________________________________ Date of Birth: _____/_____/_____
Height: _____________ Weight: _____________ % Body Fat (optional): ____________ Pulse: _________ Blood Pressure: ____ / ____ ( ____/____ , ____ /____ )
Temperature: _____________ Hearing: right: P ______ F _____ left: P _____ F _____
Visual Acuity: Right 20/_______ Left 20/_______ Corrected:
Yes
No
Pupils: Equal _________ Unequal _________
FINDINGS
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
1.
Appearance
________
________________________________________________________________________
____________
2.
Eyes/Ears/Nose/Throat
________
________________________________________________________________________
____________
3.
Lymph Nodes
________
________________________________________________________________________
____________
4.
Heart
________
________________________________________________________________________
____________
5.
Pulses
________
________________________________________________________________________
____________
6.
Lungs
________
________________________________________________________________________
____________
7.
Abdomen
________
________________________________________________________________________
____________
8.
Genitalia (males only)
________
________________________________________________________________________
____________
9.
Skin
________
________________________________________________________________________
____________
MUSCULOSKELETAL
10. Neck
________
________________________________________________________________________
____________
11. Back
________
________________________________________________________________________
____________
12. Shoulder/Arm
________
________________________________________________________________________
____________
13. Elbow/Forearm
________
________________________________________________________________________
____________
14. Wrist/Hand
________
________________________________________________________________________
____________
15. Hip/Thigh
________
________________________________________________________________________
____________
16. Knee
________
________________________________________________________________________
____________
17. Leg/Ankle
________
________________________________________________________________________
____________
18. Foot
________
________________________________________________________________________
____________
* – station-based examination only
ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Precautions: ________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________
_______________________________________________________________________________________________________________________________________
____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________
____ Referred to ______________________________________________________________________________ For: ______________________________________
_______________________________________________________________________________________________________________________________________
Recommendations: _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Name of Physician/Physician Assistant/Nurse Practitioner (print): __________________________________________________________ Date: _____/_____/_______
Address: _______________________________________________________________________________________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner: ____________________________________________________________________________________
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