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Athletic Pre-Participation Screening Exam 2020-2021The parent/guardian and student athlete will review and submit the Permit to Participate in Athletics (not this form) electronically by completing the SportsNet Online Registration.Part 1: (To be completed by student and parent/guardian)Name FORMTEXT ?????School FORMTEXT ?????Grade FORMTEXT ?????Address FORMTEXT ?????Student ID # FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Phone FORMTEXT ?????Age FORMTEXT ?????Birth Date FORMTEXT ?????Sex FORMTEXT ?????Sport(s) FORMTEXT ?????Doctor’s Name FORMTEXT ?????Doctor’s Phone # FORMTEXT ?????Health Insurance FORMTEXT ?????Policy # FORMTEXT ?????IMMUNIZATION RECORDS FOR THE ABOVE NAMED STUDENT MUST BE ATTACHED AND CURRENT AS REQUIRED BY CALIFORNIA STATE LAW INCLUDING THE Tdap VACCINE.Health History (must be complete prior to the exam)Please checkHas this student had any:Please checkIs there a history of:Y FORMCHECKBOX N FORMCHECKBOX Hospitalization?Y FORMCHECKBOX N FORMCHECKBOX Neck or back injury?Y FORMCHECKBOX N FORMCHECKBOX Surgery other than removal of tonsils?Y FORMCHECKBOX N FORMCHECKBOX Knee injury?Y FORMCHECKBOX N FORMCHECKBOX Missing organs (eye, kidney, testicle, etc.)?Y FORMCHECKBOX N FORMCHECKBOX Shoulder or elbow injury?Y FORMCHECKBOX N FORMCHECKBOX Allergies (to medicines, insects, foods, etc.)?Y FORMCHECKBOX N FORMCHECKBOX Ankle injury?Y FORMCHECKBOX N FORMCHECKBOX Chest pain or severe shortness of breath with exercise?Y FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX N FORMCHECKBOX Dislocation of a joint?Catching or locking of a joint?Y FORMCHECKBOX N FORMCHECKBOX Problems with blood pressure or heart (i.e. heart murmur)?Y FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX N FORMCHECKBOX Broken bones/fractures?Ulcers or hernias?Y FORMCHECKBOX N FORMCHECKBOX Dizziness or fainting with exercise?Y FORMCHECKBOX N FORMCHECKBOX Stingers/burners?Y FORMCHECKBOX N FORMCHECKBOX Severe or frequent headaches?Y FORMCHECKBOX N FORMCHECKBOX Skin problems?Y FORMCHECKBOX N FORMCHECKBOX Concussion or loss of consciousness? Further HistoryY FORMCHECKBOX N FORMCHECKBOX Heat exhaustion, heat stroke or other problems with heat?Y FORMCHECKBOX N FORMCHECKBOX Has any family member died suddenly at less than 40 years of age of causes other than an accident?Y FORMCHECKBOX N FORMCHECKBOX Mono, hepatitis, hemophilia?Y FORMCHECKBOX N FORMCHECKBOX Diabetes?Y FORMCHECKBOX N FORMCHECKBOX Has any family member had a heart attack at less than 55 years of age?Y FORMCHECKBOX N FORMCHECKBOX Seizures/convulsions?Use this space to explain any yes answers to the above questions.Parent’s or guardian’s acknowledgment: I have reviewed and agree with the information presented on this form. I also understand that this examination is primarily for sports participation screening and is not intended to replace the routine health care visits as recommended by the student’s personal physician. I know of no reason why the above named student should not participate and represent his or her school in supervised athletic activities. FORMTEXT ?????Name of Parent/Guardian (Print)Signature of Parent/Guardian FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home Phone NumberWork Phone NumberDateName FORMTEXT ?????Student # FORMTEXT ?????Grade FORMTEXT ?????Athletic Pre-Participation Screening Exam Part 2: General Exam (To be completed by examining physician)NormalAbnormal (Describe)Fill in Information:Eyes, ears, nose, throat FORMCHECKBOX Pulse:Skin FORMCHECKBOX BP:Lungs FORMCHECKBOX Height:Heart FORMCHECKBOX Weight:Abdomen FORMCHECKBOX Date of Physical Exam: Genitalia/Hernia (males) FORMCHECKBOX Suggested Musculoskeletal ExamROM STRENGTHNormalAbnormalCervical/SpineNormalAbnormalLower Extremity FORMCHECKBOX FORMCHECKBOX Flex/Ext FORMCHECKBOX FORMCHECKBOX Hip FORMCHECKBOX FORMCHECKBOX Rotation right/left FORMCHECKBOX FORMCHECKBOX Hip flexors/Gluteals FORMCHECKBOX FORMCHECKBOX Lateral flexion right/left FORMCHECKBOX FORMCHECKBOX Add/Abd – Groin/TT FORMCHECKBOX FORMCHECKBOX Thoracic FORMCHECKBOX FORMCHECKBOX Int./Ext. Rotation FORMCHECKBOX FORMCHECKBOX Lumbar FORMCHECKBOX FORMCHECKBOX Knee FORMCHECKBOX FORMCHECKBOX Flex/Ext FORMCHECKBOX FORMCHECKBOX Patellar Tendon FORMCHECKBOX FORMCHECKBOX Rotation right/left FORMCHECKBOX FORMCHECKBOX Tibial Tuberosity FORMCHECKBOX FORMCHECKBOX Lateral Flexion FORMCHECKBOX FORMCHECKBOX MCL/LCL FORMCHECKBOX FORMCHECKBOX Abdominals/Obliques FORMCHECKBOX FORMCHECKBOX ACL/PCLUpper Extremity FORMCHECKBOX FORMCHECKBOX Cartilage Testing FORMCHECKBOX FORMCHECKBOX Shoulder FORMCHECKBOX FORMCHECKBOX Quads/Hamstrings FORMCHECKBOX FORMCHECKBOX Forward Flexion/Ext. FORMCHECKBOX FORMCHECKBOX Gast/Soleus Comlex FORMCHECKBOX FORMCHECKBOX Abduction/Adduction FORMCHECKBOX FORMCHECKBOX Patella FORMCHECKBOX FORMCHECKBOX Internal/Ext. Rotation FORMCHECKBOX FORMCHECKBOX Crepitus FORMCHECKBOX FORMCHECKBOX Horizontal Abd/Add FORMCHECKBOX FORMCHECKBOX Tracking FORMCHECKBOX FORMCHECKBOX A C Joint/Clavicle FORMCHECKBOX FORMCHECKBOX Ankle FORMCHECKBOX FORMCHECKBOX Stability Testing FORMCHECKBOX FORMCHECKBOX Plantar/Dorsiflexion FORMCHECKBOX FORMCHECKBOX Biceps Flex/Ext. FORMCHECKBOX FORMCHECKBOX Inversion/Eversion FORMCHECKBOX FORMCHECKBOX Elbow FORMCHECKBOX FORMCHECKBOX Subtalar Joint FORMCHECKBOX FORMCHECKBOX Supination/Pronation FORMCHECKBOX FORMCHECKBOX Ligament Testing FORMCHECKBOX FORMCHECKBOX Wrist/Hand FORMCHECKBOX FORMCHECKBOX Feet/ToesGeneral FlexibilityDOCTOR’S OFFICE STAMP HEREREQUIRED FORMCHECKBOX FORMCHECKBOX Hamstrings FORMCHECKBOX FORMCHECKBOX Quadriceps FORMCHECKBOX FORMCHECKBOX Lumbar Spine FORMCHECKBOX FORMCHECKBOX AchillesUse this space to describe abnormalities.Disposition: FORMCHECKBOX Cleared for collision, contact, and non-contact sports FORMCHECKBOX Conditional participation, limited to: FORMCHECKBOX No participation until: (date) ______________ FORMCHECKBOX No participation in any sport or physical education because of: -76200193040?PHYSICAL MUST BE PERFORMED BY A LICENSED, PRACTICING MD OR NP (No Chiropractors) & MUST BE VALID FOR THE DURATION OF THE 2020-2021 SCHOOL YEAR? Physical will be valid for 1 YEAR from the Date of Physical Exam.00?PHYSICAL MUST BE PERFORMED BY A LICENSED, PRACTICING MD OR NP (No Chiropractors) & MUST BE VALID FOR THE DURATION OF THE 2020-2021 SCHOOL YEAR? Physical will be valid for 1 YEAR from the Date of Physical Exam.Dr. Signature:License #:Date: ................
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