Sports Qualifying Physical Examination Form - Bedford Public Schools
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4PHYSICAL EXAMINATION CLEARANCE FORM
This form must be on file in the school before practicing with any athletic team
Student Name: _________________________________
Birth Date: __________
Age: ____
Gender: M / F
Address: ______________________________________________________________________________________
Home Telephone: _____ - _____ - ________
School: ______________________________
Grade: ____
Sports: ___________________________________
I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check One Box)
(1) Participate in all school interscholastic activities without restrictions.
(2) Not cleared for:
All Sports
Specific Sports _________________________________________
Cross out specific sports below not cleared for participation.
Sport classification based on contact:
Collision Contact Sports
Limited Contact Sports
Non-contact Sports
Basketball
Ice Hockey
Baseball
Alpine Skiing
Track Field Events
Bowling
Track Running
Boys Lacrosse
Soccer
Competitive Cheer
Girls Softball
High Jump
Cross Country
Track Field Events
Diving
Wrestling
Girls Lacrosse
Pole Vault
Golf
Discus
Football
Girls Gymnastics
Girls Volleyball
Swimming
Shot Put
Tennis
Sport classification based on intensity and strenuousness:
High Intensity
High Intensity
High Intensity
Low Intensity
High-to-Moderate Dynamic
High-to-Moderate Dynamic
Low Dynamic
Low Dynamic
High-to-Moderate Static
Low Static
High-to-
Low Static
Moderate Static
Alpine Skiing
Track Events - Distance
Baseball
Swimming
Girls Competitive
Bowling
Cross Country
Track Events - Sprint
Lacrosse (Boys and Girls)
Tennis
Cheer
Golf
Football
Wrestling
Soccer
Girls Volleyball
Diving
Ice Hockey
Girls Softball
Field Events
Girls Gymnastics
(3) Requires further evaluation before a final recommendation can be made.
Additional recommendations for the school or parents: _____________________________________________
________________________________________________________________________________________
I have examined the above named student and completed the pre-participation physical evaluation. The athlete
does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above.
A copy of the physical exam is on record in my office and can be made available to the school at the request of
the parents. If conditions arise after the athlete has been cleared for participation, the provider may rescind the
clearance until the problem is resolved and the potential consequences are completely explained to the athlete
(and parents/guardians).
Examiner Signature: _____________________________________ DO
MD NP PA
Date of Exam: ___________
Print Examiner Name: ___________________________________
COPY BOTH SIDES OF THIS SHEET FOR
Address: ______________________________________________
THE STUDENT TO RETURN TO THE
SCHOOL AND KEEP THE ENTIRE FORM
Office Telephone: _____ - _____ - ________ _________________
IN THE STUDENTS MEDICAL RECORD
-------------------------------------------------------- < DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > ----------------------------------------------------
EMERGENCY INFORMATION FOR: ______________________
Grade: ____
Allergies – Drug Reactions – Current Medications: _________________________________________________________
Other Special Medical Information: _____________________________________________________________________
Emergency Contact: __________________________________________________ Relationship: ___________________
Telephone: (H) _____ - _____ - ________ (W) _____ - _____ - ________ (C) _____ - _____ - ________
Personal Physician ________________________________________ Office Telephone _____ - _____ - ________
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