Preparticipation Physical Evaluation - Florida High School Athletic Association (Page 5 of 9) in pdf

Preparticipation Physical Evaluation - Florida High School Athletic Association Page 5

EL2

Florida High School Athletic Association

Revised 03/10

Preparticipation Physical Evaluation

(Page 3 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.

ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)

I hereby certify that the examination(s) for which referred was/were 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: ______________________________________________________________________________________

Recommendations: _______________________________________________________________________________________________________________________

Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______

Address: _______________________________________________________________________________________________________________________________

Signature of Physician: ___________________________________________________________________________________________________________________

Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopae-

dic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.

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