Health Assessment Sports Physical Statement Page 2
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2PART B: Physical Exam
Medical Staff Assessment (Completed by licensed independent practitioner: Doctor-Dr., Nurse Practitioner-NP, Physician’s Assistant-PA)
Age
Height
Weight
YRS
MOS
__________ cm.
( _____ %ile)
__________ kgs.
(_____ %ile)
BP:
/
Visual Acuity
P:
Right
/
Left
/
Tested with / without glasses
NORMAL
ABNORMAL
N / A
COMMENTS
1. Eyes
2. Ears, Nose & Throat
3. Hearing
4. Mouth & Teeth
5. Neck (Soft tissues)
6. Cardiovascular
7. Chest & Lungs
8. Abdomen
9. Genitalia – Hernia
10. Skin & Lymphatics
11. Spine – Scoliosis
12. Extremities
13. Neurological
14. Wears braces / plates
Based on this HX and PX exam, the following abnormalities were found and may need treatment:
Immunizations are current and up to date:
Yes
No
PARTICIPATION RECOMMENDATIONS
All sports
_____Yes _____ No
Normal physical activity to including PE
Additional comments:
Restrictions:
Sports Physical is valid for 1 year from date indicated below
PART C
Special Medical Considerations: Describe any special program needs, considerations or restrictions which the child requires in order to participate in
CYS programs (to include Sports).
Child / Youth is able to participate in normal CYS programs?
Yes
No
Date
Licensed Health Care Professional Stamp
Licensed Health Care Professional; Dr., NP or PA Signature
Initial Date
Type or print name of Parent or Guardian
Signature of Parent or Guardian
HASPS Renewal (Not Part of the Sports Physical)
Year 2 Date
Health Status Changed
Signature of Parent or Guardian
Yes
No
Year 3 Date
Health Status Changed
Signature of Parent or Guardian
Yes
No
Child and Youth Services Health Assessment / Sports Physical Statement
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