CLOVIS USD SPORTS PRE-PARTICIPATION SCREENING FORM This form MUST be completed for every sports participant with parent & athlete signature

Student’s Name 	       Sex M or F	Date of Birth 	

Height: 	     Weight: 	      BMI: 	 Pulse: 	      BP: _____/_____	Hgb: __________

Vision: Grossly Intact _____	Corrected: Y or N	Pupils: Equal 	 Unequal ____

Physical Screening
	Normal Findings
	X
	Abnormal Findings
	No Exam
	
Appearance
	WDWN
				
Eyes/Ears/Nose/Throat
	WNL
				
Lymph Nodes
	WNL
				
Hearing
	Grossly Intact
				
Heart
	RRR, No Significant Murmur
				
Pulses
	WNL
				
Lungs
	Clear/equal
				
Abdomen
	Soft, No HSMT
				
Skin
	Warm/Dry/Intact
				
Neck
	FROM
				
Back
	No Scoliosis
				
Shoulder/Arm/Elbow
	FROM, = strength
				
Forearm/Wrist/Hand
	FROM, = grip/strength
				
Hip/Thigh/Knee
	FROM
				
Leg/Ankle/Foot
	FROM
				
Hernia/Squat/Duck Walk
	WNL
				
Immunizations given

CLEARANCE

	Cleared

	NOT Cleared until completed evaluation/rehabilitation for: 	

	Not cleared for: 	 Reason: 	

	Recommendations: 	

Name of Health Care Provider (print/type/stamp): 	 Date of exam: 	
Address: 	Phone:

Signature of Health Care Provider: 	Date of signature: __________

This form was developed based upon guidelines from the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Sports Medicine, the American Medical Society for Sports Medicine, the American Orthopedic Society for Sports Medicine and the American Academy of Sports Medicine, 2009.

Rev: 05/10/2013

CLOVIS USD SPORTS PRE-PARTICIPATION SCREENING FORM This form MUST be completed for every sports participant with parent/guardian & athlete signatures

Student’s Name 	 Sex M / F	Age	Date of Birth 	_ Address                                                                                                            Student ID #                                    _ Grade	School                                                            Sport(s)                                                                    _
In case of emergency, contact: Name 	 Relationship	
Phone #’s: (H)	 (W) 	 (C) 	_

Explain “YES” answers below. Circle questions you do not know the answer to.

1. Do you have any major health conditions?
2. Have you had a medical illness or injury since your last checkup or sports physical?
3. Have you even been hospitalized overnight? 4. Have you ever had surgery?
5. Are you missing an organ or body part?
6. Are you currently taking any prescription or nonprescription (over-the-counter) medications or pills?
7. Do you have any allergies to medication, food, stinging insects, or pollen?
8. Have you ever passed out or nearly passed out during or after exercise?
9. Have you ever been dizzy during or after exercise?
10. Do you get tired more quickly than your friends do during exercise?
11. Have you ever had racing of your heart or skipped heartbeats?
12. Has any family member or relative died of heart problems or of sudden death before age 50?
13. Have you had a severe viral infection such as infection of the heart or mononucleosis within the last six months?
14. Has a doctor ever told you that you have any heart problems?
If so, check all that apply:
□Heart murmur □Heart infection □High cholesterol □High blood pressure
□Kawasaki Disease □ Other:___________ 15. Has a doctor ever ordered a test for your
heart, such as ECG/EKG (Echocardiogram)? 16. Do you have any current skin problems such
as itching, rashes, acne, warts, fungus, or blisters?
17. Have you ever had a head injury or concussion?
18. Have you ever been knocked out, become

unconscious or lost your memory? 19. Have you ever had a seizure?
20. Do you have frequent or severe headaches? 21. Have you ever had numbness or tingling in
your arms, hands, legs, or feet?

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22. Have you ever had a stinger, burner, or pinched nerve?
23. Have you ever become ill from exercising in the heat?
24. Do you cough, wheeze, or have trouble breathing during or after activity?
25. Do you have asthma or use an inhaler?
If “Yes”, Do you carry your inhaler while

you are playing sports? 26. Do you have diabetes?
If “Yes”, do you take insulin?
27. Do you use any protective or corrective equipment or devices that aren’t usually
used for your sport or position, such as knee braces, special neck roll, foot orthotics, retainer on your teeth, or hearing aid?
28. Have you ever had a sprain, strain, or swelling after injury, or any problem with pain or swelling in muscles, tendons, bones, or joints?
If “Yes”, which locations: _______________ 29. Have you had any problems with your eyes
or vision, wear glasses, contact lenses, or protective eyewear?
30. For females: Age at first period: ______ Are periods regular?
31. Date of last tetanus shot: __________ Tdap date: ___________

Explain “YES” answers here: ________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

YES NO

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I hereby state, that to the best of my knowledge, my answers to all the above questions are correct and complete and I take full responsibility for any incorrect answers.
Signature of Athlete 	_ Signature of Parent/Guardian 	_ Date 	_