I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings are 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 medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
1. Have you had any of the following symptoms in the past 14 days?
If yes:
If yes:
Sources:
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Select response.)
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
(Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.)
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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