Preparticipation Physical Evaluation (Sports Physical) Note

Date/Time: [Date and time of encounter]

Patient Name: [Full name]

DOB: [Date of birth]

Age: [Age]

Sport(s): [Sport(s) for which clearance is sought]

Level/Organization: [School / club / collegiate / recreational / other]

Position/Events (if applicable): [Position or events]

Season/Year: [Season and year]

Historian(s): [athlete / parent-guardian / other] (Select all that apply)

Reason for Visit

[Statement of preparticipation evaluation for sports clearance and any specific concerns raised by athlete]

Confidentiality and Privacy

• History reviewed with parent/guardian present: [yes / no / not applicable]
• Private interview with adolescent athlete: [conducted / declined by athlete / not applicable] (If not conducted, state reason)
• [Disclosure statement confirming only medical eligibility determination will be shared with school/sports organization unless separate authorization exists; note any signed authorizations that expand disclosure]

Records and Forms Reviewed

[PPE history forms, prior PPE notes, specialist letters, relevant test results, or other records reviewed] (If none available, state "No prior records available for review")

Sports Participation Details

• Anticipated start date: [Date]
• Training volume/intensity: [Current or planned training level]
• Prior restriction or denial: [History and outcome, or none]
• Current injury status: [Active injuries or none]
• Environmental factors: [heat exposure / weight-class sport / altitude / aquatic / none significant]

PPE History

(Document positives with brief narrative explanations. Where unknown, document as "unknown" rather than inferring negatives.)

General Medical

• Ongoing conditions/PMH/PSH: [Conditions and surgical history]
• Allergies: [Allergen, reaction type, anaphylaxis history]
• Medications/Supplements: [Current medications and supplements, including performance-enhancing products]
• Loss of paired organ: [Specify organ or none]
• Vision/Hearing: [Issues or normal]
• Skin infections: [Recurrent infections or none]
• Heat illness history: [Prior episodes or none]
• Sickle cell status: [trait / disease / negative / unknown]

Cardiovascular Screening

(Document as discrete findings. If family history is unknown, document as unknown.)

• Personal history: Exertional chest pain/pressure: [yes / no]; Unexplained syncope/near-syncope with exercise: [yes / no]; Exercise intolerance or exertional palpitations: [yes / no]; Prior murmur diagnosis: [yes / no]; Prior elevated blood pressure: [yes / no]; Prior restriction for cardiac reasons: [yes / no]; Prior cardiac testing: [ECG / echo / stress test / none] with results: [findings]
• Family history (first/second-degree relatives): Premature sudden cardiac death: [yes / no / unknown]; Early disability from heart disease: [yes / no / unknown]; Known cardiomyopathy, channelopathy, Marfan syndrome, aortopathy, or arrhythmia: [yes / no / unknown]

Neurologic/Concussion History

• Prior concussions: [Number, dates, mechanism, symptom duration, time to return to school/sport, prolonged recovery or decreasing threshold, or none]
• Seizure history: [History or none]
• Transient neurologic symptoms after impact: [History or none]
• Current post-concussion symptoms: [present / absent] (If present, document explicitly and do not clear; restrict pending evaluation)

Musculoskeletal

• Prior injuries causing missed participation: [Laterality, date, treatment, current status, or none]
• Stress fracture history: [History or none]
• Current pain/instability/functional limitation: [Findings or none]
• Prior surgeries: [Procedures or none]
• Braces/taping: [Current use or none]

Respiratory/Allergy

• Exercise-induced bronchospasm/asthma: [yes / no]; triggers: [triggers]; control status: [controlled / uncontrolled]
• Rescue inhaler: [Available with athlete / available at venue / not applicable]
• Anaphylaxis history: [History and epinephrine autoinjector access plan, or none]

Menstrual/Nutrition/RED-S Risk

(Include for athletes with menstrual cycles or those in high-risk sports: endurance, aesthetic, weight-class)

• Menstrual history: [Menarche status, LMP, cycle frequency/regularity, or not applicable]
• Weight/eating concerns: [Concerns, restrictive patterns, or none identified]
• RED-S risk factors: [Findings suggestive of low energy availability, or none identified]

Mental Health Screening

• Screening tool: [PHQ-4 / other] Score: [Score] Interpretation: [negative / positive for anxiety / positive for depression / positive for both] (Note if conducted privately)
• If positive or concerns identified: Suicidal ideation: [present / absent]; Clinical assessment: [Brief summary]; Follow-up actions: [referral / safety planning / crisis resources provided / other]

Physical Examination

Vitals

• Height: [Height]
• Weight: [Weight]
• BMI: [BMI] (if used locally)
• Blood pressure: [BP] (Note position and cuff size if abnormal or elevated)
• Pulse: [Pulse]
• Vision: Right eye: [Acuity] Left eye: [Acuity] Corrected: [yes / no]

Exam Findings

(Document normal/abnormal with brief findings. Prioritize abnormalities and sport-relevant functional status.)

• General: [Appearance, body habitus, marfanoid features assessment]
• HEENT: [Findings]
• Cardiovascular: [Auscultation supine and standing; murmur characteristics and response to position change if present; femoral pulses present/symmetric]
• Pulmonary: [Findings]
• Abdominal: [Findings]
• Skin: [Lesions relevant to contact sport participation, or no concerning lesions]
• Neurologic: [Screening exam findings; baseline deficits if any]
• Musculoskeletal: [Regions examined relevant to sport and areas of concern; pain/asymmetry/instability/functional deficits; functional screening tests if performed]

Testing Performed

(Include only if testing was performed)

• Test: [ECG / spirometry / labs / imaging] Results: [Objective results] Interpretation: [Clinical interpretation]

Assessment

[Brief PPE summary: sport/level, key findings, and whether concerns require restriction or further evaluation. List any identified conditions or risk factors with sports relevance.] (If history and exam fully completed and negative, may state "No issues identified on PPE.")

Medical Eligibility Determination

Clearance Category: [Cleared for all sports without restriction / Cleared for all sports without restriction, with recommendations for further evaluation or treatment / Cleared for certain sports only (specify) / Not cleared pending further evaluation (specify) / Not cleared for any sports (with rationale)]

Rationale: [Tie determination explicitly to symptoms, exam findings, known diagnoses, pending workup, or safety considerations]

Restrictions/Accommodations: [Specific restrictions, duration, re-evaluation trigger, required equipment/access plans, or none]

Follow-up Plan: [Referrals placed or advised, results needed for clearance, responsible party, timeframe, or none needed]

Shared Decision-Making: [Participants in discussion, risks/benefits reviewed, athlete/guardian understanding, agreed plan] (Include when participation involves material risk or clinical equipoise)

Counseling Provided

[Counseling provided relevant to findings or sport context] (Document only counseling actually provided. Examples: heat illness prevention, concussion recognition/reporting, mental health resources, substance use risks, skin infection precautions for contact sports.)

Forms Completed and Distribution

• Medical record: [PPE forms stored]
• Medical Eligibility Form: [Completed and provided to athlete/parent; specify where sent if authorized]
• Releases signed: [Specify releases or none]
• Communication with athletic trainer/school: [Summary and authorization basis, or none]

(Note: Detailed history and exam findings are not released without specific authorization.)