Ihsaa Pre Participation Physical Evaluation Form Page 2
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4PHYSICAL EXAMINATION
Date:
Name:
Age:
Date of Birth:
Height:
Weight:
BP:
/
Pulse:
>
>
Vision: R 20/
L 20/
Corrected: Y N
Pupils (Circle) Equal/Unequal R
L L
R
Circle (if option given)
Specific Findings
Marfan’s syndrome stigmata
No
Yes
Heart
Rhythm
Regular
Irregular
Murmur (supine)
No
Yes
Murmur (standing)
No
Yes
Normal
Specific Findings
Lungs
Skin
Abdominal
Femoral Pulses
Genitalia/Hernia
Musculoskeletal:
Neck
Shoulders
Elbows
Wrists
Hands
Back
Knees
Ankles
Feet
Other
Clearance:
A. Cleared
B. Cleared after completing evaluation/rehabilitation for:
C. Not cleared
Due to:
Recommendation:
I hereby certify that this athlete was examined by me. At that time, no physical condition was detected which would reasonably be anticipated to render this
athlete physically unfit to engage in any sport, except those marked below:
Boys Sports: Baseball, Basketball, Cross Country, Football, Golf, Soccer, Swimming, Tennis, Track, Wrestling
Girls Sports: Basketball, Cross Country, Golf, Gymnastics, Soccer, Softball, Swimming, Tennis, Track, Volleyball
Name of Physician:
Date:
Address:
Phone: (
)
Signature of Physician:
(Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports
Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy of Sports Medicine.)
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