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 _______________________________