Special Olympics Pre-Participation Physical Evaluation
Athlete Information
Name
Date of Birth
Gender
Male
Female
Other
Address
City
State
Zip
Phone
Email
Medical History
Allergies
Current Medications
Asthma
Diabetes
Seizures
Heart Disease
Other Significant Medical History
Physical Examination
Height (cm)
Weight (kg)
Blood Pressure
Pulse
Vision
Hearing
Cardiac Exam
Musculoskeletal Exam
Other Abnormalities
Clearance
Cleared
Not cleared
If not cleared, reason:
Examiner's Information
Examiner Name
Signature
Date
License/Certification
Address