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Run: Athletic Pre-Participation Physical Evaluation Clearance Form

This Athletic Pre-Participation Physical Evaluation Clearance Form captures a student-athlete’s medical history, exam findings, and clearance decision before...

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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. (required)

Yes No N/A

Submission type (required)

Student-Athlete Information

Student full name (required)

Date of birth (required)

School name (required)

Grade level (required)

Sport(s) requesting clearance (required)

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? (required)

Asthma or breathing problem details (required)

History of concussion, head injury, or loss of consciousness? (required)

Concussion or head injury details (required)

Current symptoms that could affect safe participation? (required)

Describe current symptoms (required)

Physical Examination

Exam date (required)

Height (inches) (required)

Weight (pounds) (required)

Blood pressure

Enter in standard format, such as 118/76.

Cardiac exam findings (required)

Musculoskeletal exam findings (required)

Exam notes

Include only findings relevant to clearance, restrictions, or follow-up.

Clearance Decision

Clearance status (required)

Restriction details (required)

Follow-up required

Yes No N/A

Follow-up instructions (required)

Provider Certification and Submission

Provider name (required)

Provider credentials (required)

Provider signature (required)

Signature date (required)

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. (required)

Yes No N/A

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Email (required)

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