ADA Format Physical Form

Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM

Name: _________________________________________________________________________________   Date of birth: __________________________

PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues

• Do you feel stressed out or under a lot of pressure?

• Do you ever feel sad, hopeless, depressed, or anxious?

• Do you feel safe at your home or residence?

• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?

• During the past 30 days, did you use chewing tobacco, snuff, or dip?

• Do you drink alcohol or use any other drugs?

• Have you ever taken anabolic steroids or used any other performance supplement?

• Have you ever taken any supplements to help you gain or lose weight or improve your performance?

• Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

Height               Weight                 Male             Female
BP            /          (     /       )   Pulse                  Vision      R 20/          L     20/           Corrected  Y  N

MEDICAL                                                                                                                                                                                          

NORMAL / ABNORMAL FINDINGS
Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

• Pupils equal
• Hearing

Lymph nodes

Heart

• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)

Pulses

• Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)

Skin

• HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

 

MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional

• Duck-walk, single leg hop

• Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.

• Consider GU exam if in private setting. Having third party present is recommended.

• Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion

 Cleared for all sports without restriction

 Cleared for all sports without restriction with recommendations for further evaluation or treatment for ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 Not cleared
 Pending further evaluation
 For any sports
 For certain sports ___________________________________________________________________________________________________________________________________
Reason ___________________________________________________________________________________________________________________________________
Recommendations __________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation 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 physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician (print/type): __________________________________________________________________________ Date: ________________
Address: ________________________________________________________________________________            Phone _________________________
Signature of physician:

_______________________________________________________________________________________________________________________, MD or DO

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503 9-2681/0410

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