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  • University of Ontario Institute of Technology Pre-Participation Exam

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    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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    Original Title

    2013-14 Ridgeback PPPE Form

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    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    17 views1 page

    University of Ontario Institute of Technology Pre-Participation Exam

    Uploaded by

    StarLink1
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    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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