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University of Ontario Institute of Technology Pre-Participation Exam

This document is a pre-participation exam form for a university athlete. It collects information about the athlete like name, DOB, address and sport. It documents the results of a physical exam checking things like height, weight, ears, heart, lungs, muscles and neurological functions. At the bottom the examining physician must indicate if the athlete is fit to play based on the exam, fit pending test results, or unfit with reasons explained in comments. The physician must sign with their clinic stamp for the form to be valid.

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59 views1 page

University of Ontario Institute of Technology Pre-Participation Exam

This document is a pre-participation exam form for a university athlete. It collects information about the athlete like name, DOB, address and sport. It documents the results of a physical exam checking things like height, weight, ears, heart, lungs, muscles and neurological functions. At the bottom the examining physician must indicate if the athlete is fit to play based on the exam, fit pending test results, or unfit with reasons explained in comments. The physician must sign with their clinic stamp for the form to be valid.

Uploaded by

StarLink1
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF ONTARIO

INSTITUTE OF TECHNOLOGY
PRE-PARTICIPATION EXAM
**NOT VALID WITHOUT PHYSICIAN/CLINIC STAMP AT BOTTOM OF PAGE**

PATIENT INFORMATION
Name:

DOB:

Address:
Phone:

Sport(s):
Date:

PHYSICAL EXAM
Height:

Weight:

MEDICAL
Normal
Ear/Nose/Throat
Lymph Nodes
Heart
Pulses (femoral/radial)
Chest & Lungs
Abdomen
Skin
EYE EXAM
Visual Acuity
L:
R:
EOM
PERLA
Fundi
Equal pupil size
PULMONARY
Clear breath sounds
CARDIOVASCULAR
Murmurs
Bruits
NEUROLOGICAL
Deep tendon reflex
Cranial Nerves
Sensory
Balance
MUSCULOSKELETAL (ROM/STRENGTH)
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes

BP:

RHR:

Abnormal Findings (describe)

Initial

SUMMARY: Based on review of the medical history and physical exam I find this athlete to be:
a) Fit for play in the designated sport
b) Fit pending test results (Athlete cannot participate until cleared by results)
c) Unfit for reasons below
Comments or Information the therapist should be aware of:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

Physician Name

(Not valid without physician/clinic stamp)

Physicians Signature

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