High School Athlete Pre-Participation Medical Form
Personal Information
Name
Date of Birth
Grade
School
Sport(s)
Emergency Contact
Parent/Guardian Name
Relationship
Phone Number
Email
Address
Medical History
List any chronic medical conditions
Allergies (medicine, food, other)
Current medications
History of surgeries or hospitalizations
Does the athlete wear corrective lenses?
Yes
No
Family History
Family history of heart disease or sudden cardiac death?
Yes
No
Details (if any):
Physical Examination
Height
Weight
Blood Pressure
Pulse
Provider Clearance
Cleared for all sports:
Yes
No
If not cleared, explain:
Provider Name
Date
Provider Signature