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Facility College of Sports Medicine / American College of Sports Medicine / / IndustryTerm assistive device / unexplained car accident / / MedicalCondition myopia / Allergies / taken asthma / hypertrophic cardiomyopathy / Brugada syndrome / headaches / unexplained seizures / joint injury / catecholaminergic polymorphic ventricular tachycardia / arrhythmogenic right ventricular cardiomyopathy / heart infection / disease / headache / pressure sores / Easy bleeding Enlarged spleen Hepatitis Osteopenia / arachnodactyly / hypothermia / eye injuries / unexplained fainting / MRSA skin infection / seizure disorder / tinea corporis Neurologic / herpes / Diabetes / frequent seizures / dwarfism / pectus excavatum / hernia / juvenile arthritis / short QT syndrome / numbness / High cholesterol / pain / injury / Marfan syndrome / specific allergy / eating disorder / High blood pressure / sickle cell trait / infectious mononucleosis / muscle cramps / sudden infant death syndrome / illness / autonomic dysreflexia / hearing loss / unexplained seizure / DO EMERGENCY INFORMATION Allergies / muscle spasticity / connective tissue disease / bladder Numbness / Anemia / syndrome / head injury / Asthma / long QT syndrome / / MedicalTreatment surgery / / Organization American Academy of Family Physicians / Sports Medicine / and American Osteopathic Academy of Sports Medicine / American Medical Society for Sports Medicine / American Academy of Pediatrics / American Orthopaedic Society for Sports Medicine / College of Sports Medicine / / Position athlete / PHYSICIAN / / Technology x-ray / Sports Medicine / MRI / / SocialTag 
■■ Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM Name _ __________________________________________________________________________________ Date of birth ___________________________