Athletic Pre-Participation Physical Examination - Davenport Community School District, Iowa Page 2
ADVERTISEMENT
1
2PHYSICAL EXAMINATION RECORD (To Be Filled Out by Licensed Professional)
This evaluation is only to determine readiness for sports participation. It should not be used as a substitute for regular health
maintenance examinations.
Name ______________________________________________ Height _____________________ Weight ______________________
Pulse __________________ Blood Pressure _______________
Normal
Abnormal Findings
Initials
1. Eyes
_______________________________________________________________________________
2. Ears, Nose and Throat
_______________________________________________________________________________
3. Mouth and Teeth
_______________________________________________________________________________
4. Neck
_______________________________________________________________________________
5. Cardiovascular
_______________________________________________________________________________
6. Chest and Lungs
_______________________________________________________________________________
7. Abdomen
_______________________________________________________________________________
8. Skin
_______________________________________________________________________________
9. Musculoskeletal: ROM,
strength, etc.
_______________________________________________________________________________
10. Neurological
_______________________________________________________________________________
Comments re Abnormal Findings: _______________________________________________________________________________
____________________________________________________________________________________________________________
Participation Recommendations
_____
Full and Unlimited Participation
_____
Clearance Pending Documented Follow Up Of ______________________________________________________________
____________________________________________________________________________________________________
_____
No Athletic Participation Due To _________________________________________________________________________
____________________________________________________________________
_____________________________________
Licensed Professional's Name (Printed)
Date
____________________________________________________________________
_____________________________________
Signature
Phone
Parent's or Guardian's Permission and Release
I hereby give my consent for the above student to engage in approved athletic activities as a representative of his/her school, except those indicated
above by the licensed professional. I also give my permission for the team physician, athletic trainer, or other qualified personnel to give first aid
treatment to this student at an athletic event in case of injury.
___________________________________________________
______________________________________________________
Typed or Printed Name of Parent or Guardian
Signature of Parent or Guardian
__________________________________________________
___________________________
_________________________
Address
Phone
Date
I N S U R A N C E N O T I C E
The school district does NOT purchase an insurance policy for athletes. School time insurance is offered at a nominal fee and partially
covers all sports EXCEPT football. Football players who purchase school time insurance may also purchase a policy for football at
their own additional expense. It is agreed that the cost of any and all treatment for injury or injuries sustained by my son/daughter shall
be the responsibility of the parent (guardians) and that all such costs will be paid by us, thus releasing the schools from all financial
obligations. Participation in athletic competition may result in serious or fatal injuries.
CHECK
We plan to participate in the insurance program offered by the school
We do not wish to participate in the school
district, as outlined in the insurance letter available at registration in
district insurance program, as we have our
ONE
August. We are aware this insurance is not in effect until the form and
own insurance and/or will assume responsibi-
BOX
payment have been received by the school.
bility and costs for injuries.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical