Sports Participation Checkup

 

Child's name ____________________________________________________

I performed a complete physical exam on this patient on ________.

Medical problems: _______________________________________________

_________________________________________________________________

_________________________________________________________________

___ This child can participate in all sports and activities OR

___ This child should have limited activity as follows:

    _____________________________________________________________

    _____________________________________________________________

    _____________________________________________________________


Physician's name ________________________________________________

Physician's signature _________________________ Date ____________

Physician's phone number _______________________________