School Sports Physical Form
Florida High School Athletic Association
Preparticipation Physical Evaluation
Part 1. Student Information (to be completed by student or parent)
















Part 2. Medical History (to be completed by student or parent). Explain "yes" answers below. Select questions you don't know answers to.

Head
Neck
Back
Chest
Shoulder
Upper Arm

Elbow
Forearm
Wrist
Hand
Finger
Foot

Hip
Thigh
Knee
Shin/Calf
Ankle

Record the dates of your most recent immunizations (shots) for:



 



 


We hereby state to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida Statutes, and FHSAA By law 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assesssment, which may include diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.



 



Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse pratitioner).









HEARING


P F


P F






Medical

Appearance





Eyes/Ears/Nose/Throat





Lymph Nodes





Heart





Pulses





Lungs





Abdomen





Genitalia (males only)





Skin





Musculoskeletal

Neck





Back





Shoulder/Arm





Elbow/Forearm





Wrist/Hand





Hip/Thigh





Knee





Leg/Ankle





Foot





* - station-based examination only


Assessment of Examining Physician/Physician Assistant/Nurse Practitioner

I hereby certify that each information listed above was performed by myself or an individual under my supervision with the following conclusion(s):
















Assessment of Physician to Whom Preferred (if applicable)

I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):













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 for Sports Medicine.

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