Pre-Participation Physical Evaluation

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Pre-participation Physical Evaluation
IAW AFMAN 34-804.7.1: No child shall be eligible to participate in Maxwell/Gunter Youth Sports program unless there is on
file in the Youth Activities office a physician’s statement for the current year certifying that the child has passed an adequate
physical examination, and that in the opinion of the examining physician he/she is fully able to participate in youth sports.
Names (Child): ____________________________________
Date: ____________________________________________
Parent’s Signature: _________________________________
Physical Examination
Height _______ Weight _______ BP _______/_______ Pulse _____________
Vision R 20/_________ L 20 ___________ Corrected: Y
N
Physical Examination
Normal
Abnormal Findings
Cardiovascular
Pulses
Heart
Lungs
Skin
E.N.T
Abdominal
Genitalia (males)
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Ankle
Foot
Other (Immunization)
Clearance:
A. Cleared
B Cleared after completing evaluation/rehabilitation for: ___________
□
□
□
C. Not Cleared for:
Collision
Contact
NonContact
______ Strenuous
_______ Moderately Strenuous _______ Nonstrenuous
Due to : __________________________________
Recommendation: ___________________________________
Name of Physician _______________________________________________ Phone: _________________
Address _________________________________________________________________________
Physician’s Signature: _______________________________________
Date: _____________
Ankle

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