UIL PRE-PARTICIPATION PHYSICAL provided by Adolescent Sports Metrics

UIL PRE-PARTICIPATION SPORTS PHYSICAL EVALUATION FORM
Parents/Guardians,

To fill out your student athlete's UIL Pre-Participation Physical Evaluation Medical History form, please click the NEXT button below.

PLEASE READ IMPORTANT NOTES BELOW BEFORE STARTING FORM

Important Notes About Our Online Form:
- All pages must be filled out completely and signed in order for your student athlete to receive their physical exam.
- Both you and your student will need to provide separate signatures on the Medical History form. Please fill out the form together with your student or at a time when your student is available to provide their signature.
- If your student does not sign the form, they will NOT be able to receive a physical exam.
If you have any questions or concerns, please call our office at 469-657-5244 or email admin@adolescentsportsmetrics.org. Thank you!
How would you like to pay?*

Pay at Event (cash)
Copyright © 2021 Adolescent Sports Metrics™

PARENT/GUARDIAN CONSENT

To Pre-Participation Evaluation provided by Adolescent Sports Metrics
Confirmation of Understanding of Limited Scope and Purpose of the Extracurricular/Co-Curricular Preparticipation Physical Exams I, PARENT/GUARDIAN NAME am aware that my child/ward, CHILD NAME , will participate in preparticipation physical exams for student athletes at NAME OF SCHOOL WHERE CHILD WILL RECEIVE EXAM on DATE OF SCHEDULED EXAM . The physicals are provided by Adolescent Sports Metrics (ASM) for the sole purpose of clearing students for participation in extracurricular/co-curricular programs. The screening physical exam will be performed by health care providers deemed appropriate by the UIL (MD/DO/DC/NP/PA with a current active TEXAS license).

By signing this form, I am confirming I understand and agree to the following:
- I consent to the extracurricular/co-curricular physical exam for the above-named child;
- This is NOT a comprehensive physical exam and should not take the place of routine medical care. I understand that this is a screening physical for clearance for participation in extracurricular/co-curricular activities ONLY;
- Any patient-physician relationship created during the physical will terminate immediately upon completion of the screening physical;
- I understand that my child may need additional testing before he or she can be cleared for participation in athletic activities and it is my sole responsibility to obtain such additional testing or medical care. I understand that if it is determined that my child needs additional medical treatment, I will be notified of any such recommendation.
- I consent to the release of the results of my child’s physical screening exam to his or her school (including a coach, athletic trainer, teacher or administrator) present at the event. This consent is valid for 180 days and I understand that I may revoke this consent at any time. I understand that the information released may not be protected under the law once it is disclosed and may be subject to redisclosure by the Recipient.
Parent/Guardian's Name*

First NameLast Name
Student's Name *

First NameLast Name
Where will the student receive the physical exam? (name of school where exam will take place or ASM Office)*
Name of school where child will receive physical exam
Date of School Physical*

MonthDayYear
Date Physical scheduled to occur
RELEASE FROM LIABILITY AND INDEMNIFICATION: I hereby release, waive, discharge and covenant not to sue ASM and its subsidiaries, officers, directors, trustees, employees, agents and affiliated companies from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be caused by or related to my child’s participation or presence at the extracurricular/co-curricular Physical Examination Event. I acknowledge that I have read and understand the foregoing Release and that my signature below acknowledges the statements made in the Release.*

I DO hereby consent, on behalf of my minor child, to the screening pre-participation physical.
Student's Name *

First NameLast Name
Student School ID#*
Student Email*
example@example.com
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Date*

MonthDayYear
Today's Date
Parent/Guardian Signature*

Clear
Copyright © 2021 Adolescent Sports Metrics™

PPE MEDICAL HISTORY FORM
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an event.
Student's Name *

First NameLast Name
Student Sex:*
Student Age:*
Student Date of Birth*

MonthDayYear
Student Address*
Street #, City, Zip
Phone #*
Grade Level*
(e.g. 6th, 7th, 8th, 9th, 10th, 11th, 12th)
School District*
School Name (DISD)*
Name of DISD School student attends
School Name (MISD)*
Name of MISD School student attends
School Name (AISD)*
School Name (TISD)*
Student ID #*
Personal Physician Name*
Name of Student's Pediatrician or Doctor
Physician Phone #*
Emergency Contact Name*
Name of individual to contact in case of an emergency.
Emergency Contact - Relationship to Student*
(Example: Mother, Father, Aunt, Cousin, etc.)
Emergency Contact - HOME Phone #*
Emergency Contact - WORK Phone #*
Copyright © 2021 Adolescent Sports Metrics™

An electrocardiogram (ECG) is NOT REQUIRED.

Select "NO" below if you do NOT wish to obtain an ECG for your student for additional cardiac screening AT YOUR OWN EXPENSE.

Select "YES" below if you DO wish to obtain an ECG for your student for additional cardiac screening AT YOUR OWN EXPENSE. By selecting "YES," you are indicating that you have read and understand the information about cardiac screening and that you understand it is the responsibility of your family to schedule and pay for such ECG.
NO, I do NOT wish to obtain an ECG for my student at my own expense.YES, I do wish to obtain an ECG for my student at my own expense.
It is understood that even though protective equipment is worn by athletes, whenever needed, the possibility of an accident still remains. Neither the University Intersc holastic League nor the school assumes any responsibility in case an accident occurs.

If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and tr eatment as may be given said student by any physician, athletic tr ainer, nurse or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.

If, between this date and the beginning of participation, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury.
Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE, PERFORMANCE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL.
Student Signature*

Clear
Parent/Guardian Signature*

Clear
Date:*

MonthDayYear
Date

Athletic Trainer Name*
Date Reviewed by Athletic Trainer:*

MonthDayYear
Date
Athletic Trainer Signature*

Clear

Student Name*

First NameLast Name
School ID*
Should be Empty:

UIL PRE-PARTICIPATION SPORTS PHYSICAL EVALUATION FORM

PARENT/GUARDIAN CONSENT

PPE MEDICAL HISTORY FORM

MEDICAL HISTORY

PHYSICAL EXAMINATION

MEDICAL

MUSCULOSKELETAL