Fhsaa El 2 Form PDF Details

The FHSAA El 2 form is used to report athletic eligibility. This form must be completed by the student and the parent or guardian, and must be submitted to the school before the start of each sports season. The FHSAA El 2 form is used to report academic eligibility, as well as any disciplinary action taken against the student athlete. It is important to ensure that all information reported on this form is accurate, so that the student athlete can maintain their eligibility to participate in sports games and competitions.

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Question	Answer
Form Name	Fhsaa El 2 Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	el2 physical form, el2 form 2020, el2 physical evaluation, florida high school athletic association el2

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EL2

Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 1 of 3)

REVISED 03/16

This completed form must be kept on ile by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

Part 1. Student Information (to be completed by student or parent)

Student’s Name: ________________________________________________________________________ Sex: _____ Age: _____ Date of Birth: _____/ _____/ _____

School: ____________________________________________________ Grade in School: _____ Sport(s): ________________________________________________

Home Address: _______________________________________________________________________________________ Home Phone: ( _____) _______________

Name of Parent/Guardian: _______________________________________________________________ E-mail: ___________________________________________

Person to Contact in Case of Emergency: _____________________________________________________________________________________________________

Relationship to Student: _______________________ Home Phone: ( _____) ______________ Work Phone: ( _____) _____________ Cell Phone: ( _____) _____________

Personal/Family Physician: ___________________________________________City/State: ___________________________ Ofice Phone: ( _____) _____________

Part 2. Medical History (to be completed by student or parent). Explain “yes” answers below. Circle questions you don’t know answers to.

		Yes	No
1.	Have you had a medical illness or injury since your last	____	____
	check up or sports physical?
2.	Do you have an ongoing chronic illness?	____	____
3.	Have you ever been hospitalized overnight?	____	____
4.	Have you ever had surgery?	____	____
5.	Are you currently taking any prescription or non-	____	____
	prescription (over-the-counter) medications or pills or
	using an inhaler?
6.	Have you ever taken any supplements or vitamins to	____	____
	help you gain or lose weight or improve your
	performance?
7.	Do you have any allergies (for example, pollen, latex,	____	____
	medicine, food or stinging insects)?
8.	Have you ever had a rash or hives develop during or	____	____
	after exercise?
9.	Have you ever passed out during or after exercise?	____	____
10.	Have you ever been dizzy during or after exercise?	____	____
11.	Have you ever had chest pain during or after exercise?	____	____
12.	Do you get tired more quickly than your friends do	____	____
	during exercise?
13.	Have you ever had racing of your heart or skipped	____	____
	heartbeats?
14.	Have you had high blood pressure or high cholesterol?	____	____
15.	Have you ever been told you have a heart murmur?	____	____
16.	Has any family member or relative died of heart	____	____
	problems or sudden death before age 50?
17.	Have you had a severe viral infection (for example,	____	____
	myocarditis or mononucleosis) within the last month?
18.	Has a physician ever denied or restricted your	____	____
	participation in sports for any heart problems?
19.	Do you have any current skin problems (for example,	____	____
	itching, rashes, acne, warts, fungus, blisters or pressure sores)?
20.	Have you ever had a head injury or concussion?	____	____
21.	Have you ever been knocked out, become unconscious	____	____
	or lost your memory?
22.	Have you ever had a seizure?	____	____
23.	Do you have frequent or severe headaches?	____	____
24.	Have you ever had numbness or tingling in your arms,	____	____
	hands, legs or feet?
25. Have you ever had a stinger, burner or pinched nerve?		____	____

					Yes	No
26.	Have you ever become ill from exercising in the heat?				____	____
27.	Do you cough, wheeze or have trouble breathing during or after				____	____
	activity?
28.	Do you have asthma?				____	____
29.	Do you have seasonal allergies that require medical treatment?				____	____
30.	Do you use any special protective or corrective equipment or				____	____
	medical devices that aren’t usually used for your sport or position
	(for example, knee brace, special neck roll, foot orthotics, shunt,
	retainer on your teeth or hearing aid)?
31.	Have you had any problems with your eyes or vision?				____	____
32.	Do you wear glasses, contacts or protective eyewear?				____	____
33.	Have you ever had a sprain, strain or swelling after injury?				____	____
34.	Have you broken or fractured any bones or dislocated any joints?				____	____
35.	Have you had any other problems with pain or swelling in muscles,				____	____
	tendons, bones or joints?
	If yes, check appropriate blank and explain below:
	___ Head	___ Elbow		___ Hip
	___ Neck	___ Forearm		___ Thigh
	___ Back	___ Wrist		___ Knee
	___ Chest	___ Hand		___ Shin/Calf
	___ Shoulder	___ Finger		___ Ankle
	___ Upper Arm	___ Foot
36.	Do you want to weigh more or less than you do now?				____	____
37.	Do you lose weight regularly to meet weight requirements for your				____	____
	sport?
38.	Do you feel stressed out?				____	____
39.	Have you ever been diagnosed with sickle cell anemia?				____	____
40.	Have you ever been diagnosed with having the sickle cell trait?				____	____
41.	Record the dates of your most recent immunizations (shots) for:
	Tetanus: _______________		Measles: _______________
	Hepatitus B: ____________		Chickenpox: ____________

FEMALES ONLY (optional)

42.When was your irst menstrual period? _______________________

43.When was your most recent menstrual period? _________________

44.How much time do you usually have from the start of one period to the start of another?_______________________________________

45.How many periods have you had in the last year? _______________

46.What was the longest time between periods in the last year? ________

Explain “Yes” answers here:_______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.

Signature of Student: _____________________________________ Date: ____/ ____/ ____ Signature of Parent/Guardian: __________________________________ Date: ____/ ____/ ____

– 1 –

EL2

Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 2 of 3)

REVISED 03/16

This completed form must be kept on ile by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physi- cian, licensed physician assistant or certiied advanced registered nurse practitioner).

Student’s Name: _____________________________________________________________________________________________ Date of Birth: _____/_____/_____

Height: _____________ Weight: _____________ % Body Fat (optional): ____________ Pulse: _________ Blood Pressure: ____ / ____ ( ____/____ , ____ /____ )

Temperature: _____________ Hearing: right: P ______ F _____ left: P _____ F _____
Visual Acuity: Right 20/_______		Left 20/_______	Corrected: Yes	No	Pupils: Equal _________ Unequal _________
FINDINGS		NORMAL			ABNORMAL FINDINGS	INITIALS*
MEDICAL
1.	Appearance	________	________________________________________________________________________			____________
2.	Eyes/Ears/Nose/Throat	________	________________________________________________________________________			____________
3.	Lymph Nodes	________	________________________________________________________________________			____________
4.	Heart	________	________________________________________________________________________			____________
5.	Pulses	________	________________________________________________________________________			____________
6.	Lungs	________	________________________________________________________________________			____________
7.	Abdomen	________	________________________________________________________________________			____________
8.	Genitalia (males only)	________	________________________________________________________________________			____________
9.	Skin	________	________________________________________________________________________			____________
MUSCULOSKELETAL
10.	Neck	________	________________________________________________________________________			____________
11.	Back	________	________________________________________________________________________			____________
12.	Shoulder/Arm	________	________________________________________________________________________			____________
13.	Elbow/Forearm	________	________________________________________________________________________			____________
14.	Wrist/Hand	________	________________________________________________________________________			____________
15.	Hip/Thigh	________	________________________________________________________________________			____________
16.	Knee	________	________________________________________________________________________			____________
17.	Leg/Ankle	________	________________________________________________________________________			____________
18.	Foot	________	________________________________________________________________________			____________

* – station-based examination only

ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER

I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):

____ Cleared without limitation

____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________

_______________________________________________________________________________________________________________________________________

____ Precautions: ________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________

_______________________________________________________________________________________________________________________________________

____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________

____ Referred to ______________________________________________________________________________ For: ______________________________________

_______________________________________________________________________________________________________________________________________

Recommendations: _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Name of Physician/Physician Assistant/Nurse Practitioner (print): __________________________________________________________ Date: _____/_____/_______

Address: _______________________________________________________________________________________________________________________________

Signature of Physician/Physician Assistant/Nurse Practitioner: ____________________________________________________________________________________

– 2 –

EL2

Florida High School Athletic Association

Preparticipation Physical Evaluation (Page 3 of 3)

REVISED 03/16

This completed form must be kept on ile by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

Student’s Name: _____________________________________________________________________________________________

ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)

I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):

____ Cleared without limitation

____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________

_______________________________________________________________________________________________________________________________________

____ Precautions: ________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________

____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________

Recommendations: _______________________________________________________________________________________________________________________

Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______

Address: _______________________________________________________________________________________________________________________________

Signature of Physician: ___________________________________________________________________________________________________________________

Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopae- dic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.

– 3 –

How to Edit Fhsaa El 2 Form Online for Free

It really is very easy to fill in the el2 physical form. Our PDF editor was meant to be help you complete any PDF efficiently. These are the basic actions to take:

Step 1: The very first step is to hit the orange "Get Form Now" button.

Step 2: The file editing page is now available. Include text or enhance existing information.

If you want to prepare the template, type in the content the platform will request you to for each of the following sections:

Type in the details in the after exercise, Have you ever passed out during, during exercise, Have you ever had racing of your, heartbeats, Have you had high blood pressure, problems or sudden death before, Have you had a severe viral, Do you have any current skin, itching rashes acne warts fungus, Have you ever had a head injury, or lost your memory, Have you ever had a seizure Do, hands legs or feet, and Have you ever had a stinger field.

fhsaa 2021 after exercise, Have you ever passed out during, during exercise, Have you ever had racing of your, heartbeats, Have you had high blood pressure, problems or sudden death before, Have you had a severe viral, Do you have any current skin, itching rashes acne warts fungus, Have you ever had a head injury, or lost your memory, Have you ever had a seizure Do, hands legs or feet, and Have you ever had a stinger blanks to complete

Write any details you may need in the area Explain Yes answers here, We hereby state to the best of our, and Signature of Student Date.

Indicate the rights and responsibilities of the sides inside the box Part Physical Examination to be, Height Weight Body Fat optional, Temperature Hearing right P F, Visual Acuity Right Left, FINDINGS, MEDICAL, NORMAL, ABNORMAL FINDINGS, INITIALS, Appearance, EyesEarsNoseThroat, Lymph Nodes, Heart, Pulses, and Lungs.

End by taking a look at all these fields and filling them in as required: HipThigh, Knee, LegAnkle, Foot, stationbased examination only, ASSESSMENT OF EXAMINING, I hereby certify that each, Cleared without limitation, Disability Diagnosis, Precautions, Not cleared for Reason, Cleared after completing, Referred to For, Recommendations, and Name of PhysicianPhysician.

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