Sports pre-participation physical
Pediatrics

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

PARTICIPATION
Sport or activity and level: [ ]
Patient and parent or caregiver present: [ ]

HISTORY
Screening questionnaire used and responses reviewed: [ ]
Symptoms with exercise as reported: [ ]
Family history of sudden cardiac death or inherited heart conditions as reported: [ ]
Prior injuries, concussions and surgeries: [ ]
Medications and allergies: [ ]

EXAMINATION
Vitals measured, with units: [ ]
Vision screening result if performed: [ ]
Cardiovascular examination findings: [ ]
Musculoskeletal examination findings: [ ]
Other examination findings: [ ]

CLEARANCE DECISION
Cleared, cleared with conditions, or not cleared, and reasoning: [ ]
Further evaluation or referral needed: [ ]
Form completed and given to whom: [ ]