Athletic Pre-Participation Physical Evaluation Clearance Form

Documents a student-athlete’s sports physical, medical history, and clearance status before interscholastic participation.

Submission Purpose

• Purpose of this submission
• I understand this form collects personal and health information for athletic clearance and may be shared with authorized school or clinical staff involved in the clearance process.
• Submission type

Student-Athlete Information

• Student full name
• Date of birth
• School name
• Grade level
• Sport(s) requesting clearance

Medical History Screening

• Current medications
  List only medications relevant to sports participation or clearance.
• Allergies
  Include medication, food, or environmental allergies that may affect participation or emergency care.
• History of asthma or exercise-induced breathing problems?
• Asthma or breathing problem details
• History of concussion, head injury, or loss of consciousness?
• Concussion or head injury details
• Current symptoms that could affect safe participation?
• Describe current symptoms

Physical Examination

• Exam date
• Height (inches)
• Weight (pounds)
• Blood pressure
  Enter in standard format, such as 118/76.
• Cardiac exam findings
• Musculoskeletal exam findings
• Exam notes
  Include only findings relevant to clearance, restrictions, or follow-up.

Clearance Decision

• Clearance status
• Restriction details
• Follow-up required
• Follow-up instructions

Provider Certification and Submission

• Provider name
• Provider credentials
• Provider signature
• Signature date
• I certify that the information provided is accurate to the best of my knowledge and that the clearance decision is based on the evaluation documented in this form.