PRE-COMPETITION MEDICAL ASSESSMENT(PCMA)

PRE-COMPETITION MEDICAL ASSESSMENT(PCMA)
PLAYER:
Name
First NameLast Name
Gender:
Age:
Date of Birth:
MonthDayYear
Date
Club:
School/Job:
Employer:
Sport:
Next of Kin:
First NameLast Name
Relation:
Home:
Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
Cellular:
Format: (000) 000-0000.
Next of Kin:
First NameLast Name
Relation:
Home:
Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
Cellular:
Format: (000) 000-0000.
Date of Assessment:
MonthDayYear
Date
MEDICAL HISTORY
PRESENT AND PAST COMPLAINTS
GENERAL
Rows NO YES
Infections (esp. Viral) (within the last four weeks) 1 2
Diarrhea illness 3 4
Rheumatic fever 5 6
Heat illness
7 8
Concussion 9 10
Allergies 11 12
Asthma 13 14
HEART AND LUNGS
Rows NO AT REST DURING/AFTER EXERCISE
Chest pain or tightness 15 16 17
Palpitations/Arrhythmias
Other heart problems
18 19 20
Respiratory problems
Dizziness
21 22 23
Syncope 24 25 26
ADDITIONAL HEART AND LUNGS
Rows NO YES
Hypertension 27 28
Heart murmurs 29 30
Abnormal lipid profile 31 32
Seizures, Epilepsy 33 34
Advised to give up sport 35 36
Tired more quickly than team-mates 37 38
Blood pressure reading (mmHg)
Pulse (bpm)
Respiratory rate
SpO2 Reading (%)
Blood Glucose (mg/dl or mmol/l)
Additional notes:
MUSCULOSKELETAL SYSTEM
NOT APPLICABLE
Severe injury leading to more than four weeks of limited participation or absence from playing/training:
Rows RIGHT LEFT MOST RECENT OCCURRENCE (YEAR)
Groin strain 40 41
strain of quadriceps femurs muscles 42 43
Hamstring strain 44 45
Knee ligament injury 46 47
Ankle ligament 48 49
Other (please specify below) 50 51
Other:
MUSCILOSKELTAL SURGERY
MUSCULOSKELETAL SURGERY
Rows RIGHT LEFT MOST RECENT OPERATION (when?) YEAR
Hip joint 52 53
Groin 54 55
Knee ligaments 56 57
Knee meniscus or cartilage
58 59
Achilles tendon 60 61
Ankle joint 62 63
Other operations (please specify below) 64 65
Other:
Current complaint aches or pains:
BODY PARTS
ADDITIONAL BODY PARTS
Rows RIGHT LEFT
Hip 66 67
Groin 68 69
Thigh 70 71
Knee 72 73
Lower leg 74 75
Achilles tendon 76 77
Ankle 78 79
Foot, toe 80 81
CURRENT DIAGNOSIS AND TREATMENT

Rows	NO	YES
Infections (esp. Viral) (within the last four weeks)	1	2
Diarrhea illness	3	4
Rheumatic fever	5	6
Heat illness	7	8
Concussion	9	10
Allergies	11	12
Asthma	13	14

Rows	NO	AT REST	DURING/AFTER EXERCISE
Chest pain or tightness	15	16	17
Palpitations/Arrhythmias Other heart problems	18	19	20
Respiratory problems Dizziness	21	22	23
Syncope	24	25	26

Rows	NO	YES
Hypertension	27	28
Heart murmurs	29	30
Abnormal lipid profile	31	32
Seizures, Epilepsy	33	34
Advised to give up sport	35	36
Tired more quickly than team-mates	37	38

Rows	RIGHT	LEFT	MOST RECENT OCCURRENCE (YEAR)
Groin strain	40	41
strain of quadriceps femurs muscles	42	43
Hamstring strain	44	45
Knee ligament injury	46	47
Ankle ligament	48	49
Other (please specify below)	50	51

Rows	RIGHT	LEFT	MOST RECENT OPERATION (when?) YEAR
Hip joint	52	53
Groin	54	55
Knee ligaments	56	57
Knee meniscus or cartilage	58	59
Achilles tendon	60	61
Ankle joint	62	63
Other operations (please specify below)	64	65

Rows	RIGHT	LEFT
Hip	66	67
Groin	68	69
Thigh	70	71
Knee	72	73
Lower leg	74	75
Achilles tendon	76	77
Ankle	78	79
Foot, toe	80	81

CURRENT DIAGNOSIS AND TREATMENT

Rows	RIGHT	LEFT	REST	PHYSIOTHERAPY	SURGERY
Groin	82	83	84	85	86
Hamstring strain	87	88	89	90	91
Quadriceps strain	92	93	94	95	96
Knee sprain	97	98	99	100	101
Meniscus lesion	102	103	104	105	106
Tendinosis of Achilles tendon	107	108	109	110	111
Ankle sprain	112	113	114	115	116
Concussion	117	118	119	120	121
Lower back pain	122	123	124	125	126

FAMILY HISTORY (Male relatives

Rows	NO	FATHER	MOTHER	SIBLING	OTHER
Sudden cardiac death	127	128	129	130	131
Sudden infant death (SID)	132	133	134	135	136
Coronary heart disease	137	138	139	140	141
Cardiomyopathy	142	143	144	145	146
Hypertension	147	148	149	150	151
Recurrent syncope	152	153	154	155	156
Arrhythmia	157	158	159	160	161
Heart transplant	162	163	164	165	166
Heart surgery	167	168	169	170	171
Pacemaker/defibrillator	172	173	174	175	176
Marfan syndrome	177	178	179	180	181
Unexplained drowning	182	183	184	185	186
Unexplained car accident	187	188	189	190	191
Stroke	192	193	194	195	196
Diabetes	197	198	199	200	201
Cancer	202	203	204	205	206
Other (arthritis etc)	207	208	209	210	211

ROUTINE MEDICATION WITHIN THE LAST 12 MONTHS
Please specify
MUSCULOSKELETAL SYSTEM
SPINAL COLUMN AND PELVIC LEVEL
SPINAL FORM
PELVIC
Rows EVEN MEASUREMENTS (CM) LOWER RIGHT LEFT
PELVIC LEVEL 213 214
SACROILIAC JOINT
CERVICAL ROTATION
Rows DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 215 216
LEFT 217 218
SPINAL FELXION
Rows MEASUREMENTS (CM)
DISTANCE FINGERTIPS TO FLOOR
EXAMINATION OF HIPS, GROINS AND THIGHS
HIP FLEXIBILITY
FLEXION (passive)
Rows NORMAL LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 219 220 221
LEFT 222 223 224
EXTENSION (passive)
Rows NORMAL LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 225 226 227
LEFT 228 229 230
INWARD ROTATION (in 90º flexion)
Rows LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 231 232
LEFT 233 234
OUTWARD ROTATION (in 90º flexion)
Rows LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 235 236
LEFT 237 238
ABDUCTION
Rows LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 239 240
LEFT 241 242
TENDERNESS ON GROIN PALPATION
Rows NO PUBIS INGUINAL CANAL
RIGHT 243 244 245
LEFT 246 247 248
HERNIA
Rows NO YES, PLEASE SPECIFY BELOW
RIGHT 249 250
LEFT 251 252
HERNIA SPECIFICS
MUSCLES
ADDUCTORS
Rows NORMAL SHORTENED PAINFUL (NO) PAINFUL (YES)
RIGHT 253 254 255 256
LEFT 257 258 259 260
HAMSTRINGS
Rows NORMAL SHORTENED PAINFUL (NO) PAINFUL (YES)
RIGHT 261 262 263 264
LEFT 265 266 267 268
ILIOPOAS
Rows NORMAL SHORTENED PAINFUL (NO) PAINFUL (YES)
RIGHT 269 270 271 272
LEFT 273 274 275 276
RECTUS FEMORIS
Rows NORMAL SHORTENED PAINFUL (NO) PAINFUL (YES)
RIGHT 277 278 279 280
LEFT 281 282 283 284
TENSOR FASCIAE LATAE MUSCLE (iliotibial band)
Rows NORMAL SHORTENED PAINFUL (NO) PAINFUL (YES)
RIGHT 285 286 287 288
LEFT 289 290 291 292
EXAMINATION OF KNEES
KNEE-JOINT AXIS
Rows NORMAL GENU VARUM GENU VALGUM
RIGHT 293 294 295
LEFT 296 297 298
FLEXION (passive)
Rows NORMAL LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 299 300 301
LEFT 302 303 304
EXRTENSION (passive)
Rows 0º LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES) HYPEREXTENSION DEGREES (º)
RIGHT 305 306 307 308
LEFT 309 310 311 312
LACHMAN TEST
Rows NORMAL + ++ +++
RIGHT 313 314 315 316
LEFT 317 318 319 320
ANTERIOR DRAWER SIGN (knee joint 90º flexion)
Rows NORMAL + ++ +++
RIGHT 321 322 323 324
LEFT 325 326 327 328
POSTERIOR DRAWER SIGN (knee joint 90º flexion)
Rows NORMAL + ++ +++
RIGHT 329 330 331 332
LEFT 333 334 335 336
VALGUS STRESS, IN EXTENSION
Rows NORMAL + ++ +++
RIGHT 337 338 339 340
LEFT 341 342 343 344
VALGUS STRESS, IN 30º FLEXION
Rows NORMAL + ++ +++
RIGHT 345 346 347 348
LEFT 349 350 351 352
VARUS STRESS, IN EXTENSION
Rows NORMAL + ++ +++
RIGHT 353 354 355 356
LEFT 357 358 359 360
VARUS STRESS, IN 30º FLEXION
Rows NORMAL + ++ +++
RIGHT 361 362 363 364
LEFT 365 366 367 368
JOINT LINE TENDERNESS
Rows NORMAL + ++ +++
RIGHT MEDIAL 369 370 371 372
RIGHT LATERAL 373 374 375 376
LEFT MEDIAL 377 378 379 380
LEFT LATERAL 381 382 383 384
EXAMINATION OF LOWER LEG, ANKLE AND FOOT
TENDERNESS OF ACHILLES TENDON
Rows NO YES
RIGHT 385 386
LEFT 387 388
ANTERIOR DRAWER SIGN
Rows NORMAL + ++ +++
RIGHT 389 390 391 392
LEFT 393 394 395 396
DORSI-FLEXION
Rows LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 397 398
LEFT 399 400
PLANTAR FLEXION
Rows LIMITED DEGREES (º) PAINFUL (NO) PAINFUL (YES)
RIGHT 401 402
LEFT 403 404
TOTAL SUPINATION
Rows NORMAL DECREASED INCREASED
RIGHT 405 406 407
LEFT 408 409 410
TOTAL PRONATION
Rows NORMAL DECREASED INCREASED
RIGHT 411 412 413
LEFT 414 415 416
METATARSOPHALANGEAL JOINT
Rows NORMAL PATHOLOGICAL
RIGHT 417 418
LEFT 419 420
NAME OF EXAMINING PERSON
First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Rows	EVEN	MEASUREMENTS (CM) LOWER	RIGHT	LEFT
PELVIC LEVEL			213	214

Rows	DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		215	216
LEFT		217	218

Rows	MEASUREMENTS (CM)
DISTANCE FINGERTIPS TO FLOOR

Rows	NORMAL	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT	219		220	221
LEFT	222		223	224

Rows	NORMAL	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT	225		226	227
LEFT	228		229	230

Rows	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		231	232
LEFT		233	234

Rows	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		235	236
LEFT		237	238

Rows	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		239	240
LEFT		241	242

Rows	NO	PUBIS	INGUINAL CANAL
RIGHT	243	244	245
LEFT	246	247	248

Rows	NO	YES, PLEASE SPECIFY BELOW
RIGHT	249	250
LEFT	251	252

Rows	NORMAL	SHORTENED	PAINFUL (NO)	PAINFUL (YES)
RIGHT	253	254	255	256
LEFT	257	258	259	260

Rows	NORMAL	SHORTENED	PAINFUL (NO)	PAINFUL (YES)
RIGHT	261	262	263	264
LEFT	265	266	267	268

Rows	NORMAL	SHORTENED	PAINFUL (NO)	PAINFUL (YES)
RIGHT	269	270	271	272
LEFT	273	274	275	276

Rows	NORMAL	SHORTENED	PAINFUL (NO)	PAINFUL (YES)
RIGHT	277	278	279	280
LEFT	281	282	283	284

Rows	NORMAL	SHORTENED	PAINFUL (NO)	PAINFUL (YES)
RIGHT	285	286	287	288
LEFT	289	290	291	292

Rows	NORMAL	GENU VARUM	GENU VALGUM
RIGHT	293	294	295
LEFT	296	297	298

Rows	NORMAL	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT	299		300	301
LEFT	302		303	304

Rows	0º	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)	HYPEREXTENSION DEGREES (º)
RIGHT	305		306	307	308
LEFT	309		310	311	312

Rows	NORMAL	+	++	+++
RIGHT	313	314	315	316
LEFT	317	318	319	320

Rows	NORMAL	+	++	+++
RIGHT	321	322	323	324
LEFT	325	326	327	328

Rows	NORMAL	+	++	+++
RIGHT	329	330	331	332
LEFT	333	334	335	336

Rows	NORMAL	+	++	+++
RIGHT	337	338	339	340
LEFT	341	342	343	344

Rows	NORMAL	+	++	+++
RIGHT	345	346	347	348
LEFT	349	350	351	352

Rows	NORMAL	+	++	+++
RIGHT	353	354	355	356
LEFT	357	358	359	360

Rows	NORMAL	+	++	+++
RIGHT	361	362	363	364
LEFT	365	366	367	368

Rows	NORMAL	+	++	+++
RIGHT MEDIAL	369	370	371	372
RIGHT LATERAL	373	374	375	376
LEFT MEDIAL	377	378	379	380
LEFT LATERAL	381	382	383	384

Rows	NO	YES
RIGHT	385	386
LEFT	387	388

Rows	NORMAL	+	++	+++
RIGHT	389	390	391	392
LEFT	393	394	395	396

Rows	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		397	398
LEFT		399	400

Rows	LIMITED DEGREES (º)	PAINFUL (NO)	PAINFUL (YES)
RIGHT		401	402
LEFT		403	404

Rows	NORMAL	DECREASED	INCREASED
RIGHT	405	406	407
LEFT	408	409	410

Rows	NORMAL	DECREASED	INCREASED
RIGHT	411	412	413
LEFT	414	415	416

Rows	NORMAL	PATHOLOGICAL
RIGHT	417	418
LEFT	419	420

Select theme:

PRE-COMPETITION MEDICAL ASSESSMENT(PCMA)

MEDICAL HISTORY

MUSCULOSKELETAL SYSTEM

MUSCULOSKELETAL SYSTEM

EXAMINATION OF HIPS, GROINS AND THIGHS

MUSCLES

EXAMINATION OF KNEES

EXAMINATION OF LOWER LEG, ANKLE AND FOOT