Preparticipation Physical Evaluation Form

Preparticipation Physical Evaluation Form

**Please fill out this form before participating in any physical activity or sport.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship*
Medical History
List any medications you are currently taking
Have you ever had any of the following conditions or injuries?*

Heart conditionAsthmaDiabetesSeizuresSprains/StrainsFracturesConcussionsOther
Do you have any current physical limitations or restrictions?*
Do you have any Allergies?*
Please provide any additional information or concerns
Have you ever had surgery?
Please provide any additional information or concerns
Name of Healthcare Provider and phone number (Pediatric)*
Date of Last Physical Examination*

MonthDayYear
Date
I acknowledge that this visit is for the purpose of a Sports Physical Examination only. I understand that NO immunizations or routine pediatric care will be provided during this appointment.

I agree to follow up with my child’s primary care provider or pediatrician for any necessary immunizations, routine check-ups, or additional medical concerns.
Parent/Guardian Signature*

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Medical History