Medical Clearance Form for Adaptive Sports Athletes
Athlete Information
Full Name
Date of Birth
Gender
Adaptive Sport
Medical History
Primary Diagnosis / Disability
Other Medical Conditions
Allergies
Current Medications
Physical Examination
Height
Weight
Blood Pressure
Pulse
Relevant Examination Findings
Preparticipation Clearance
This athlete is medically cleared for adaptive sports participation:
Yes
Yes, with restrictions
Not cleared
If restrictions/recommendations, please specify:
Provider Information
Provider Name
Signature
Date