Piaa Comprehensive Initial Pre-Participation Physical Evaluation And Certification Of Authorized Medical Examiner
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1S
6: PIAA C
I
P
-P
P
E
ECTION
OMPREHENSIVE
NITIAL
RE
ARTICIPATION
HYSICAL
VALUATION
C
A
M
E
AND
ERTIFICATION OF
UTHORIZED
EDICAL
XAMINER
Must be completed and signed by the Authorized Medical Examiner (AME) performing the herein named student’s comprehensive
initial pre-participation physical evaluation (CIPPE) and turned in to the Principal, or the Principal’s designee, of the student's school.
Student’s Name
Age
Grade
Enrolled in _______________________________________ School
Sport(s)
Height_______ Weight______ % Body Fat (optional) ______ Brachial Artery BP_____/_____ (_____/_____ , _____/_____) RP_______
If either the brachial artery blood pressure (BP) or resting pulse (RP) is above the following levels, further evaluation by the student’s
primary care physician is recommended.
Age 10-12: BP: >126/82, RP: >104; Age 13-15: BP: >136/86, RP >100; Age 16-25: BP: >142/92, RP >96.
Vision: R 20/_____ L 20/_____
Corrected: YES
NO (circle one)
Pupils: Equal_____ Unequal_____
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
Eyes/Ears/Nose/Throat
Hearing
Lymph Nodes
Heart murmur
Femoral pulses to exclude aortic coarctation
Cardiovascular
Physical stigmata of Marfan syndrome
Cardiopulmonary
Lungs
Abdomen
Genitourinary (males only)
Neurological
Skin
MUSCULOSKELETAL
NORMAL
ABNORMAL FINDINGS
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
I hereby certify that I have reviewed the H
H
, performed a comprehensive initial pre-participation physical evaluation of the
EALTH
ISTORY
herein named student, and, on the basis of such evaluation and the student’s H
H
, certify that, except as specified below,
EALTH
ISTORY
the student is physically fit to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in the sport(s) consented to
by the student’s parent/guardian in Section 2 of the PIAA Comprehensive Initial Pre-Participation Physical Evaluation form:
CLEARED
CLEARED, with recommendation(s) for further evaluation or treatment for:
NOT CLEARED for the following types of sports (please check those that apply):
C
C
N
-
S
M
S
N
-
OLLISION
ONTACT
ON
CONTACT
TRENUOUS
ODERATELY
TRENUOUS
ON
STRENUOUS
Due to
Recommendation(s)/Referral(s)
AME’s Name (print/type)
License #
Address______________________________________________________________________ Phone (
)
AME’s Signature____________________
Certification Date of CIPPE ___/____/___
MD, DO, PAC, CRNP, or SNP (circle one)
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Section 5: Health History, Section 6: Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
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Section 6: Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
Education
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