Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Sports Physical Clearance Form
Your information
Athlete Full Name
Date of Birth
____ / ____ / ________
Sport and Position
Parent/Guardian Name
Parent/Guardian Phone
Cardiac Symptom Screening
Family Cardiac History
Additional details
Concussion History
Prior Musculoskeletal Injuries
Current Medications
| Medication | Dose | How often |
|---|---|---|
Musculoskeletal Screening
Risk Acknowledgment
Clearance Determination
Provider Signature
Date
Sports Physical Clearance Form template from formisoft.com. formisoft.com/intake-templates/sports-physical-clearance