Sports Physical Exam Checklist Form
Complete this checklist to document the results of a pre-participation sports physical exam.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sport or Activity
*
Please Select
Soccer
Basketball
Track and Field
Swimming
Tennis
Other
Examiner Name
*
Blood Pressure (mmHg)
*
Heart Rate (bpm)
*
Has the participant experienced chest pain during exercise?
*
No
Yes
Has the participant experienced dizziness or fainting with activity?
*
No
Yes
Clearance Outcome
*
Cleared for all sports without restriction
Cleared with recommendations for further evaluation or treatment
Not cleared for sports participation
Submit Checklist
Should be Empty: