ADA Format Physical Form
Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________________________ Date of birth: __________________________
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).
Height Weight Male Female
BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N
NORMAL / ABNORMAL FINDINGS
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
• Pupils equal
• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)
• Simultaneous femoral and radial pulses
Genitourinary (males only)
• HSV, lesions suggestive of MRSA, tinea corporis
• 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 ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pending further evaluation
For any sports
For certain sports ___________________________________________________________________________________________________________________________________
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.