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Sports Physical Clearance Form

2 pages•14 fields•HIPAA-ready
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Sports Physical Clearance Form

Page 1 of 2

Athlete Full Name
Jane Martinez
Date of Birth
03/15/1985
Sport and Position
Parent/Guardian Name
Jane Martinez
Parent/Guardian Phone
(555) 867-5309
Cardiac Symptom Screening
Fatigue
Pain
Nausea
Dizziness
Shortness of breath
Family Cardiac History
Option A
Option B
Option C
Concussion History
Option A
Option B
Option C
Prior Musculoskeletal Injuries
Enter details here...
Current Medications
Musculoskeletal Screening
Risk Acknowledgment
Item 1 assessed
Item 2 assessed
Item 3 assessed
Clearance Determination
Option A
Option B
Option C
Provider Signature
Sign here
Submit
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The Sports Physical Clearance Form provides a standardized pre-participation physical evaluation workflow used to assess whether a student athlete is medically fit to compete. It captures the athlete's personal information, sport and position, and a detailed medical history focused on cardiac symptoms, concussion history, musculoskeletal injuries, and exercise-related conditions. This thorough screening helps identify risk factors before the season begins and satisfies school and athletic association requirements.

The form includes a family cardiac history section that screens for sudden cardiac death risk factors, a musculoskeletal screening checklist covering joint stability and range of motion, and questions about prior concussions with return-to-play timelines. Athletes and their parents acknowledge the inherent risks of sports participation, and the examining provider documents their clearance determination along with any sport-specific restrictions or recommended follow-up evaluations.

Designed for sports medicine clinics, pediatric practices, family medicine offices, and school athletic departments that manage large volumes of pre-season physicals. Whether clearing athletes for contact sports like football and wrestling or endurance activities like cross-country and swimming, this form ensures a consistent evaluation process that protects athlete safety and satisfies governing body requirements.

What's included

  • Athlete demographics, sport, and position identification
  • Cardiac symptom and family history screening questionnaire
  • Concussion history and return-to-play timeline documentation
  • Musculoskeletal screening checklist and injury history
  • Risk acknowledgment and parental consent capture
  • Provider clearance determination with signature
  • Structured medication list with dosage and frequency tracking

Who uses this template

  • Pre-season athletic clearance for high school and college sports
  • Sports medicine clinic pre-participation evaluations
  • Return-to-play clearance after injury or concussion
  • Youth recreational league physical requirement compliance

All form fields

14 fields across 2 pages. Customize any field after signing up.

Athlete Full NameText
Date of BirthDate
Sport and PositionText
Parent/Guardian NameText
Parent/Guardian PhonePhone
Cardiac Symptom ScreeningCheckbox
Family Cardiac HistoryMultiple Choice
Concussion HistoryMultiple Choice
Prior Musculoskeletal InjuriesLong Text
Current MedicationsMedications
Musculoskeletal ScreeningCheckbox
Risk AcknowledgmentCheckbox
Clearance DeterminationMultiple Choice
Provider SignatureE-Signature
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