Sports/Activity Clearance Letter (Pediatric Cardiology)

[Practice or Clinic Name]
[Address Line 1]
[Address Line 2]
Phone: [Practice phone] | Fax: [Practice fax]

Date of Letter: [Date of letter]

Date of Evaluation: [Date of evaluation]

To: [School nurse / Athletic director / Coach / To Whom It May Concern (School/Athletics)]

Re: [Patient full name], DOB: [Date of birth]

At the request of [patient and/or parent/guardian], this letter addresses cardiovascular clearance for participation in [specific sport(s) / school physical education and organized athletics]. This determination addresses cardiovascular considerations only and is based on information available as of [date of evaluation].

Clinical Summary

Primary cardiac diagnosis or reason for cardiology involvement: [Primary cardiac diagnosis or reason for referral]

Current symptom status: [Exertional syncope, chest pain, and palpitations status — state "denies," "present," or "not assessed" for each; do not infer negatives if not documented]

(If symptom screening was not performed, state: "Symptom screening was not performed as part of this letter; clearance is limited accordingly.")

Relevant testing: [Pertinent cardiac testing with dates and high-level interpretations — e.g., ECG, echocardiogram, stress test, ambulatory monitoring as applicable] (Include only tests relevant to the clearance decision.)

[Shared decision-making statement] (If applicable for higher-risk conditions: briefly note that risks and alternatives were discussed with the family and the participation plan reflects their informed preferences.)

Clearance Determination

Determination: [Cleared for full participation with no cardiovascular restrictions / Cleared with restrictions / Not cleared at this time / Conditionally cleared pending (specific condition or timeframe)]

(If "Not cleared," state what must occur before reconsideration and anticipated timeframe.)

Restrictions: [No cardiovascular restrictions / List applicable restrictions with measurable language — intensity limits, contact/collision limits, lifting/straining limits, environmental considerations, supervision/AED access requirements, device-specific precautions]

Validity: This clearance is valid through [specific date or next scheduled follow-up date].

Emergency Action Plan

1. Recognize emergency: collapse, unresponsiveness, severe chest pain, sustained palpitations with dizziness, or syncope during activity.
2. Call 911 immediately.
3. Begin CPR if unresponsive and not breathing normally.
4. Apply AED as soon as available and follow prompts.

(If ICD/pacemaker present: "AED should still be applied if unresponsive; the implanted device is not a contraindication." If on anticoagulation: "Inform EMS of anticoagulation medication.")

Follow-up and Stop Criteria

Follow-up: [Follow up with Pediatric Cardiology in X months / as scheduled on (date)]

Stop activity and seek medical evaluation if: exertional syncope or near-syncope, chest pain or pressure with exertion, new or worsening palpitations, or unusual shortness of breath or exercise intolerance. If febrile illness with cardiopulmonary symptoms develops, seek guidance before returning to intense exercise.

Please contact our office at [contact phone/email] with any questions. This letter contains only information necessary for school athletic participation planning and is provided with parent/guardian request.

Sincerely,

[Clinician full name], [Credentials]
Pediatric Cardiology
[Practice/Clinic Name]
[Direct phone/email]