brevaSports pre-participation physical
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: [ ]