Sports/School Physical Examination & Clearance Note (PPE)

Date: [Date]   Location: [Clinic/Facility]   Clinician: [Name, credentials]

Patient: [Full name]   DOB: [DOB]

Sport(s)/Activity: [List]   Level: [middle school / high school / club / college / other]   Season/Start Date: [Date or season]   PPE Type: [initial / annual update]

Parent/Guardian Present (if minor): [yes / no / N/A]   Historian: [athlete / parent-guardian / both]   Confidential Interview: [yes / no]

Reason for Visit

[Statement indicating preparticipation physical evaluation for sports/school clearance] (Include a scope note that this is a focused evaluation for participation risk stratification and clearance, not equivalent to a comprehensive preventive visit unless those elements were separately performed.)

Forms Required: [School athletic form / state physical form / organization-specific form / none]

History Questionnaire Status

Questionnaire Completion: [completed prior to visit / completed during visit / not completed]

Reviewed With: [athlete / parent-guardian / both]

Incomplete or Missing Items: [List sections or questions not answered, or "none"] (If clearance-driving questions—cardiac symptoms, family sudden death history, current injuries, concussion symptoms—are unanswered, explicitly state whether clearance can proceed or must be deferred.)

History

Sports Profile: [Sport(s), position/event, contact/collision level, protective equipment used, requested accommodations]

Medical History: [Active medical conditions; prior sports participation restrictions; recent illness; surgeries/hospitalizations; current medications including supplements; allergies with anaphylaxis history]

Cardiovascular Screening (Each item requires an explicit yes/no response; do not leave blank or infer negatives. If yes, add brief narrative. If unknown and clearance-affecting, state that clearance cannot be finalized.)

• Exertional chest pain/pressure/tightness: [yes / no / unknown] — [Narrative if yes]
• Exertional syncope or near-syncope: [yes / no / unknown] — [Narrative if yes]
• Exertional palpitations or disproportionate dyspnea/fatigue: [yes / no / unknown] — [Narrative if yes]
• Known heart condition or murmur: [yes / no / unknown] — [Diagnosis, prior clearance status, current management if yes]
• Prior cardiac testing (ECG/echo/stress test): [yes / no] — [Type, date, results if yes]
• History of elevated blood pressure: [yes / no / unknown] — [Details and treatment if yes]
• Family history of sudden unexplained death before age 50: [yes / no / unknown] — [Relation, age, context if yes]
• Family history of inherited cardiac conditions (HCM, channelopathies, Marfan, ARVC): [yes / no / unknown] — [Condition, relation if yes]
• Family history of early pacemaker/ICD or unexplained arrhythmia: [yes / no / unknown] — [Relation, age, context if yes]

(Do not document cardiac disease as ruled out based on history/physical alone; instead document "no concerning findings on screening" when appropriate.)

Musculoskeletal: [Prior fractures or stress fractures; injuries causing missed participation; surgeries/rehabilitation; current pain/instability/swelling; functional limitations] (Detail any active issues.)

Neurologic: [Seizure history; concussion history with number, dates, recovery time; current post-concussion symptoms; episodes of numbness/tingling/weakness or transient paralysis after impact]

Respiratory: [Exercise-induced symptoms; asthma diagnosis and control status; rescue inhaler availability]

Other Medical Concerns: [Heat illness history; sickle cell trait/disease status; bleeding disorders; missing paired organs with protective considerations; contagious skin conditions relevant to contact sports]

Vision/Hearing: [Vision problems; corrective lenses; sport-specific eyewear needs; hearing concerns]

Nutrition and Weight: [Weight concerns; attempts to gain/lose weight; special diets; eating disorder history] (For weight-class or leanness-emphasized sports, document additional screening.))

Menstrual History: [Menarche status; last menstrual period; cycle regularity; number of periods in last 12 months / not applicable]

Mental Health and Risk Behaviors: [Validated screening result if used (e.g., PHQ-4 score and interpretation); positive findings for depression/anxiety; sleep concerns; safety issues; tobacco/vaping; alcohol; marijuana/other drugs; supplement or performance-enhancing drug use] (Keep sensitive details appropriately limited; note if separate confidential documentation exists.)

Physical Examination

Vitals: Height [value], Weight [value], BMI [value]; Blood Pressure [value] (repeat if elevated: [value]); Pulse [value]

Vision Screening: Right [uncorrected / corrected: value], Left [uncorrected / corrected: value], Bilateral [value]

Hearing Screening: [Method and results / not performed]

Exam Findings (Document normal vs abnormal for each system; briefly describe abnormalities. Do not populate as normal unless actually assessed.)

• General: [Appearance, hydration, distress; Marfan habitus assessment if indicated]
• HEENT/Lymph: [Findings]
• Cardiovascular: [Auscultation supine and standing; rate/rhythm; murmurs with timing/grade/response to maneuvers; femoral pulses]
• Lungs: [Effort; breath sounds]
• Abdomen: [Organomegaly; masses; tenderness]
• Skin: [Contagious lesions relevant to participation]
• Neurologic: [Gross deficits; balance/coordination if assessed]
• Musculoskeletal: [Neck; back; upper extremity; lower extremity with ROM/strength/stability where indicated; functional screening tests with pass/fail and notes on deficits]

Genitourinary: [performed with indication / not performed / not indicated] (If performed, document chaperone: [present / offered and declined].)

Tests: [Tests performed with indication and results] (If none: no screening tests indicated or performed.)

Assessment

[One-sentence PPE summary synthesizing whether screening history and exam are normal or notable for specific findings]

Potential participation-limiting findings: [List concerning issues such as exertional syncope requiring workup, uncontrolled asthma, suspected concussion, concerning murmur, significant hypertension, or "none"]

Participation-compatible conditions requiring action plans: [e.g., asthma with rescue inhaler access, anaphylaxis with epinephrine, prior injuries requiring monitoring, or "none"]

Other issues identified: [Brief list, or "none"]

(When restriction or conditional clearance is considered, document that risks, benefits, and alternatives were discussed with the athlete and parent/guardian if minor.)

Plan

Clearance Decision: [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 restrictions) / Not cleared pending further evaluation / Not cleared for any sports] (Select exactly one category.)

Restrictions: [Specific activities restricted; duration or endpoint; required protective equipment; warning symptoms requiring immediate stop / none]

Follow-up and Referrals: [Referral destination and urgency; specific questions for consultant; whether clearance will be updated upon results; re-check visit requirements / none needed]

Emergency Preparedness: [Emergency medications/devices needed at practice or competition; action plans provided; athletic trainer/school nurse communication plan / not applicable]

Counseling Provided: [Topics addressed: hydration/heat illness prevention, concussion education and symptom reporting, nutrition and safe weight management, mental health resources, substance use, sport-specific injury prevention; handouts or resources provided]

Form Completion: [Attestation that clinician examined the athlete and completed PPE; eligibility may be rescinded if new conditions arise. Information released to school/athletics (eligibility status and emergency-relevant data) via (method). Detailed documentation maintained in medical record.]