Fhsaa El 2 Form – Fill Out and Use

EL2

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.

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: ____/ ____/ ____

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EL2

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: ____ / ____ ( ____/____ , ____ /____ )

* – 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: ____________________________________________________________________________________

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EL2

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.

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