El2 Physical Form 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.

Below is the details about the file you were in search of to fill in. It can tell you how much time it will require to complete fhsaa el 2 form, what parts you will need to fill in and a few further specific details.

QuestionAnswer
Form NameFhsaa El 2 Form
Form Length3 pages
Fillable?Yes
Fillable fields207
Avg. time to fill out21 min 4 sec
Other namesel2 physical evaluation, fhsaa physical form, el2 form, el2 form 2020

Form Preview Example

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 –

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