Fillable PRE-PARTICIPATION PHYSICAL EVALUATION 2021-2022 SCHOOL YEAR

Fill Online, Printable, Fillable, Blank PRE-PARTICIPATION PHYSICAL EVALUATION 2021-2022 SCHOOL YEAR Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PRE-PARTICIPATION PHYSICAL EVALUATION 2021-2022 SCHOOL YEAR

On average this form takes 57 minutes to complete

The PRE-PARTICIPATION PHYSICAL EVALUATION 2021-2022 SCHOOL YEAR form is 3 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 218 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 119a
PRE-PARTICIPATION PHYSICAL EVALUATION
2021-2022 SCHOOL YEAR
To be completed by the Parent for School:
STUDENT NAME: DOB: ______________AGE: _____GENDER: ______
HOME ADDRESS:
SCHOOL: GRADE: SPORT(s):
FATHER/GUARDIAN
NAME:___________________________________________________
EMAIL: __________________________________________________
CELL PHONE: ____________________________________________
FATHER’S
EMPLOYER:______________________________________________
WORK PHONE: ___________________________________________
MOTHER/GUARDIAN
NAME:________________________________________________________
EMAIL: _______________________________________________________
CELL PHONE: __________________________________________________
MOTHER’S
EMPLOYER:____________________________________________________
WORK PHONE: _________________________________________________
EMERGENCY CONTACTS
NAME:_____________________________________________________________
PHONE:____________________________________________________________
EMAIL: ____________________________________________________________
RELATIONSHIP:____________________________________________________
NAME:___________________________________________________________
PHONE:__________________________________________________________
EMAIL: __________________________________________________________
RELATIONSHIP:___________________________________________________
PHYSICIAN NAME: PHONE:
INSURANCE PROVIDER: POLICY NUMBER:
NAME OF INSURED: GROUP NUMBER:
MEDICINES: List all prescription, over the counter, and supplements student is currently taking:
Parental Consent
I grant permission for my child to participate in extracurricular athletic activities. These activities will take place under the guidance and
direction of school employees and/or volunteers. As a parent and/or legal guardian, I remain legally responsible for personal actions
taken by my participating child I agree on behalf of myself, my participating child, our heirs, successors and assigns, to hold harmless
and defend the school, its employees, officers, directors and agents, and the Archdiocese of Galveston-Houston, or representatives
associated with these activities, arising from our in connection with my child participating in these activities, or in connection with any
illness, injury or cost of medical treatment in connection therewith, and I agree to compensate the school, its officers, directors and
agents, and the Archdiocese of Galveston-Houston, or representatives associated with the activity for reasonable attorney’s fees or
expenses arising in connection therewith. I hereby warrant to the best of my knowledge, that my child is in good health, and I assume
all responsibility for the health and medical care of my child. In the event of a medical emergency, I hereby give permission to school
employees and/or volunteers supervising the athletic event to obtain medical services and to transport my child to the nearest
hospital/emergency care center for emergency medical or surgical treatment.
Parent/Guardian Signature: Date:
Page 1 of 3
click to sign
signature
click to edit
Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 119b
PRE-PARTICIPATION PHYSICAL EVALUATION
2021-2022 SCHO
OL YEAR
To be completed by the Physician/Licensed Examiner for School:
STUDENT NAME: DATE OF BIRTH: AGE: ________
EXAMINATION
Height: Weight: Pulse: Blood Pressure: ________/_________
Vision R 20/________L 20/________ Corrected: Yes______ No_______ Pupils: Equal ______ Unequal _____
Hearing: Normal_____ Referred_____ Spinal Exam: Normal_____Referred______ % Body Fat (optional)
NORMAL
ABNORMAL FINDINGS
NORMAL
ABNORMAL FINDINGS
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant
Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a Doctor of Chiropractic.
Examination forms signed by any other health care practitioner, will not be accepted.
CLEARANCE
Cleared for all sports without restriction
Cleared for all sports without restriction with recommendations for further evaluation or treatment for:
________________________________________________________________________________
Not cleared
Pending further evaluation
For any sport
For certain sports:
Reason: _______________________________________________________________________
Recommendations: ______________________________________________________________
Physician/Clinician Signature: _________________________________________________________________________
Physician/Clinician Print Name: ________________________________________________________________________
Address:___________________________________________________________________________________________
Phone: ______________________________________________ Date of Exam: _______________________________
Page 2 of 3
click to sign
signature
click to edit
Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 119c
PRE-PARTICIPATION PHYSICAL EVALUATION
2021-2022 SCHOOL YEAR
To be completed by the Parent for Healthcare Provider:
DIRECTIONS: Complete questions below and explain “YES” answers in the space provided.
GENERAL QUESTIONS
YES
NO
UNSURE
1. Has your doctor ever denied or restricted your participation in sports for any reason?
2. Do you have any ongoing medical conditions? If so check all that apply: Asthma Anemia Diabetes
Infections Other:_____________________________________________________________________
3. Have you ever spent the night in the hospital in the past year?
4. Have you ever had surgery?
HEART HEALTH QUESTIONS
YES
NO
UNSURE
5. Have you ever passed out or nearly passed out during or after exercise?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
7. Does your heart ever race or skip beats (irregular beats) during exercise?
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure High cholesterol Kawasaki disease A heart murmur A heart infection
Other: _______________________________________________________________________________
9. Do you get lightheaded or feel more short of breath than expected during exercise?
10. Have you ever had an unexplained seizure?
11. Do you get more tired or short of breath more quickly than your friends during exercise?
FAMILY HEART HEALTH QUESTIONS
YES
NO
UNSURE
12. Has any family member or relative died of heart problems or unexpected sudden death before age 50?
13. Has any family member been diagnosed with a heart condition?
BONE AND JOINT QUESTIONS
YES
NO
UNSURE
14. Have you had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or game?
15. Have you had any fractured bones or dislocated joints?
16. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast?
17. Do you regularly use a brace, orthotics or other assistive device?
18. Do any of your joints become painful, swollen, feel warm or look red?
MEDICAL QUESTIONS
YES
NO
UNSURE
19. Do you cough, wheeze, or have difficulty breathing during or after exercise?
20. Do you have any allergies? If so, check all that apply: Pollen Medicine Food Stinging Insects
Other: _______________________________________________________________________________
21. Are you missing any paired organs?
22. Have you had a severe viral infection (myocarditis, mononucleosis, etc.) in the past year?
23. Do you currently have any skin problems (itching, acne, warts, fungus, or blisters)?
24. Have you ever had a head injury or concussion?
25. Have you ever been knocked unconscious or lost memory?
26. Do you have a history of seizure disorder?
27. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
28. Have you ever become ill while exercising in the heat?
29. Have you been diagnosed with or treated for Sickle Cell Trait or Sickle Cell Disease?
30. Have you had any problems with your eyes or vision?
31. Have you ever had unexpected shortness of breath with exercise?
32. Have you had any eye injuries?
33. Do you use any special protective or corrective equipment?
34. Do you lose weight regularly to meet weight requirements for an extra-curricular activity?
35. Are you on a special diet or do you avoid certain foods?
36. Have you ever had an eating disorder?
37. Are you presently under a doctor’s care?
38. Do you have any concerns you would like to discuss with a doctor?
FEMALES ONLY
39. What year was your first menstrual cycle?
40. What month and day was your most recent menstrual cycle?
41. How many cycles have you had in the last 12 months?
Explain “YES” answers:
Page 3 of 3
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PRE-PARTICIPATION PHYSICAL EVALUATION 2021-2022 SCHOOL YEAR

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document