North Carolina High School Athletic Association Sport Preparticipation Examination Form Page 2

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Athlete’s Name
Age
Date of Birth
Height
Weight
BP
(_____% ile) / ________(_____% ile)
Pulse
Vision R 20/
L 20/
Corrected: Y N
Physical Examination (Below Must be Completed by Licensed Physician, Nurse Practitioner or Physician Assistant)
These are required elements for all examinations
NORMAL
ABNORMAL
ABNORMAL FINDINGS
PULSES
HEART
LUNGS
SKIN
NECK/BACK
SHOULDER
KNEE
ANKLE/FOOT
Other Orthopedic
Problems
Optional Examination Elements – Should be done if history indicates
HEENT
ABDOMINAL
GENITALIA (MALES)
HERNIA (MALES)
Clearance:
q
A. Cleared
q
B. Cleared after completing evaluation/rehabilitation for :
q
*** C. Medical Waiver Form must be attached (for the condition of: ____________________________________________________________)
q
q
q
D. Not cleared for:
Collision
Contact
q
Non-contact
______Strenuous ______Moderately strenuous ______Non-strenuous
Due to:
Additional Recommendations/Rehab Instructions:
Name of Physician/Extender:
Signature of Physician/Extender
MD
DO
PA
NP
(Signature and circle of designated degree required)
Date of exam:
Physician Office Stamp:
Address:
Phone
________________________________________________________________________________________________
(*** The following are considered disqualifying until appropriate medical and parental releases are obtained: post-operative clearance, acute infections,
obvious growth retardation, uncontrolled diabetes, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or Stage 2
hypertension, enlarged liver or spleen, a chronic musculoskeletal condition that limits ability for safe exercise/sport (i.e. Klippel-Feil anomaly, Sprengel’s
deformity), history of uncontrolled seizures, absence of/ or one kidney, eye, testicle or ovary, etc.)
This form is approved by the North Carolina High School Athletic Association Sports Medicine Advisory Committee and the NCHSAA Board of Directors.
This form is current as of April 2015.

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