Priory Athletics

302 Portola Road, Portola Valley, Ca 94028, 650-851-6128

Pre-Participation Examination

Part 1: History (to be completed by parent or guardian)

Name:____________________________________________ SSN:__________________ Sex:___ Date of Birth:_________ Grade:___

Last First MI

Address:______________________________________________________________________________________________________

Student's Home Phone:____________________ Student's Cell Phone:____________________ Other Number:_____________________

Doctor�s Name/ Clinic:______________________________________________________ Phone:______________________________

Health Insurance:___________________________________________ Policy #:____________________ Group #:_________________

Emergency Contact Person:______________________________ Relationship to Student:____________ Home Phone:______________

Cell Phone:____________________________ Work Phone:__________________________ Other Number:______________________

Health History (Must be completed prior to physical examination):

Date of Last Known Tetanus Shot:____________________

Has the student had any: Is there a history of:

___YES ___NO Hospitalizations or Surgery? ___YES ___NO Neck or Back Pain?

___YES ___NO Missing Organs (Eye, Kidney, Testicle)? ___YES ___NO Hand or Wrist Injury?

___YES ___NO Skin Problems? ___YES ___NO Shoulder or Elbow Injury?

___YES ___NO Chest Pain? ___YES ___NO Hip or Thigh Injury?

___YES ___NO Severe Shortness of Breath? ___YES ___NO Knee Injury?

___YES ___NO Asthma? ___YES ___NO Ankle or Foot Injury?

___YES ___NO Problems with Blood Pressure or the Heart? ___YES ___NO Catching or Clicking of a Joint?

___YES ___NO Dizziness or Fainting with Exercise? ___YES ___NO Broken Bones or Fracture?

___YES ___NO Severe or Frequent Headaches? ___YES ___NO Stingers/Burners?

___YES ___NO Concussion or Loss of Consciousness? ___YES ___NO Ulcers or Hernias?

___YES ___NO Heat Exhaustion or Heat Stroke? ___YES ___NO Corrective Lens?

___YES ___NO Mono, Hepatitis, Hemophilia?

___YES ___NO Diabetes? Further History:

___YES ___NO Seizures or Convulsions? ___YES ___NO Has any family member at less than 40 years

___YES ___NO Allergies? of age died suddenly other than an accident?

___YES ___NO Currently taking any Prescription or ___YES ___NO Has any family member had a heart attack Non-Prescription Medications?

at less than 55 years of age?

Use this space to explain any YES answers to the above questions. Please indicate right or left, date of injury, treatment or any current complaints.

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Parent's or Guardian's Permission to Play and Assumption of Risk:

I have reviewed and agree with the information presented on this form. I also understand that this examination is primarily for sports participation screening and

is not intended to replace the routine health care visits as recommended by the student's personal physician. I know of no reason why the above named student should

not participate and represent his or her school in supervised athletic activities. I am aware that with participation in sports comes the risk of injury to my child/ward.

I understand that the degree of danger and seriousness of the risk vary significantly from one sport to another. I am aware that Woodside Priory School is no way

responsible for any injuries that my child/ward might incur as a result of such participation. With this knowledge in mind, I grant permission for my child/ward to

participate in athletics. In the event of an emergency, I authorize the coach, athletic trainer, or school authorities to obtain medical aid and/or ambulance transportation

at my expense.

_____________________________________________________________________________________________________________

Print Name of Parent or Guardian Signature of Parent or Guardian Date

______________________________________________________________________________________________________________

Home Phone Work Phone Cell Phone

Part 2: Physical Examination (To be completed by the examining Physician)

Location	Normal	Abnormal (please describe)	Vitals
Eyes, Ears, Nose, Throat			Pulse:
Lungs			BP:
Heart			Height:
Abdomen			Weight:
Genitalia/Hernia (Males)			Vision:

Suggested Musculoskeletal Examination

Cervical Spine: Hip:

____NL ____AB Flex/Ext ____NL ____AB Hip Flexors

____NL ____AB Rotation R/L ____NL ____AB Glutes

____NL ____AB Lateral Flex R/L ____NL ____AB Abduction/Adduction

Thoracic/Lumbar: ____NL ____AB IT Band

____NL ____AB Flex/Ext ____NL ____AB Internal/External Rotation

____NL ____AB Rotation R/L Knee:

____NL ____AB Lateral Flex R/L ____NL ____AB Patella Tendon

____NL ____AB Abdominals/Obliques ____NL ____AB Tibial Tuberosity

Shoulder: ____NL ____AB MCL

____NL ____AB Flex/Ext ____NL ____AB LCL

____NL ____AB Abduction/Adduction ____NL ____AB ACL

____NL ____AB Internal/External Rotation ____NL ____AB Meniscus

____NL ____AB Horizontal ABD/ADD ____NL ____AB Quads

____NL ____AB AC Joint/Clavicle ____NL ____AB Hamstrings

____NL ____AB Stability Testing ____NL ____AB Patella Tracking

____NL ____AB Impingement Testing Ankle/Foot:

Elbow/Wrist: ____NL ____AB Gastroc/Soleus Complex

____NL ____AB Elbow Flex/Ext ____NL ____AB Achilles Tendon

____NL ____AB Elbow Supination/Pronation ____NL ____AB Plantar/Dorsiflexion

____NL ____AB Wrist ____NL ____AB Inversion/Eversion

____NL ____AB Hand/Fingers ____NL ____AB Subtalar Joint

____NL ____AB Ligament Testing

____NL ____AB Feet/Toes

Describe Abnormals:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Current Medications:_________________________________________________________________________________________________

Disposition:

Cleared for collision, contact and non-contact sports: ____YES ____NO

Conditional Participation, limited to:

______________________________________________________________________________________________________________

No Participation until:

______________________________________________________________________________________________________________

Comments: ____________________________________________________________________________________________________

______________________________________________________________________________________________________________

M.D. Signature: ______________________________________________________________ License #:_________________________

Physician's Name (Please print or stamp)______________________________________________________Date:___________________

Address and Phone Number:_______________________________________________________________________________________