Initial Physical Exam Form printable pdf download

Health Exam Form B, Updated September, 2011

FORM B

USE THIS FORM WHEN FORM A (Initial Physical Exam Form) IS ON FILE

Instructions for completing FORM B

1. PLEASE TYPE OR PRINT LEGIBLY

2. Once Form A is on file at the school, each subsequent year the parent/guardian with the

student are to complete the Health History on page 3 of Form B and the Disclosure and

Consent Document on page 2. Please note student and parent are to sign both forms.

3. Entire completed form is to be returned to school administration.

4. School personnel are to review this form to assure it is completed properly. A

recommendation to clear a student for participation or require a re-evaluation physical exam is

made based upon this form. Each year the Health History (page 3) must be completed by the

parent/guardian with the student and if there are changes in any answers from the most recent

form filed then the clearance form below must be completed and signed by an appropriate

health care professional (MD, DO, PAC, RNP, DC).

5. ORIGINAL copy is to be retained in school files.

Forms A and B along with the Disclosure and Consent Document must be on file at the school

before any participation in athletic activities.

The re-evaluation health examination may be completed and the form signed by any Medical

Doctor (MD), Doctor of Osteopathy (DO), Physician’s Assistant (PAC), Chiropractic Physician (DC),

or Registered Nurse Practitioner (RNP) functioning within the legal scope of their practice.

THE UTAH HIGH SCHOOL ACTIVITIES ASSOCIATION DOES NOT PROVIDE PRINTED

COPIES OF THIS FORM. PLEASE MAKE ALL NECESSARY COPIES.

Pre-participation Physical Re-evaluation

CLEARANCE FORM B

Student Name___________________________________________ School_______________________________________

Cleared

Cleared after completing evaluation/rehabilitation for______________________________________

____________________________________________________________________________________

Not cleared for___________________________ Reason____________________________________

____________________________________________________________________________________

Name of Physician/Provider (Print/type)______________________________________________Date__________________

Address__________________________________________________________________ Phone______________________

Signature of Physician/Provider___________________________________________________

Form B, Updated September, 2011

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Initial Physical Exam Form