To submit this form, you may need to send it to the appropriate address provided by the requesting organization. This could include emailing a scanned copy to their specified email address, faxing it to 813-445-7340, or mailing it to their physical address. Always check with the organization for their preferred method of submission. It's advisable to keep a copy of the filled and submitted form for your records.

Ensure to get your physical exam form completed and submitted before sports season starts. Deadlines might vary based on the organization, so check with your respective administration for specific dates in 2024 and 2025.

The purpose of this form is to ensure that individuals participating in sports or physical activities are medically fit and healthy. By documenting personal information, medical history, and the results of a thorough physical examination, this form helps to identify any potential health risks. It serves as a preventive measure, protecting both the participants and the organizations hosting the activities.

• 1. Date: The date on which the form is being filled out.
• 2. Patient name: The full legal name of the patient.
• 3. Age: The age of the patient.
• 4. Date of Birth: The date of birth of the patient.
• 5. Blood Pressure: The blood pressure reading of the patient.
• 6. Current Medications: Details of any medications the patient is currently taking.
• 7. Allergies: Information about any known allergies the patient has.
• 8. Medical & Surgical Hx: The patient's medical and surgical history.
• 9. Pulse: The patient's pulse rate.
• 10. Height: The height of the patient.
• 11. Weight: The weight of the patient.
• 12. Temp: The temperature of the patient.
• 13. Review of Systems: A review documenting any abnormalities in the patient's body systems.
• 14. HEENT: Assessment of Head, Eyes, Ears, Nose, and Throat.
• 15. Cardiovascular: Assessment of the cardiovascular system.
• 16. Respiratory: Assessment of the respiratory system.
• 17. Gastrointestinal: Assessment of the gastrointestinal system.
• 18. Musculoskeletal: Assessment of the musculoskeletal system.
• 19. Skin: Assessment of the patient's skin.
• 20. Neurological: Assessment of the neurological system.
• 21. Genitourinary: Assessment of the genitourinary system.
• 22. Physician's Signature: Signature of the physician completing the examination.
• 23. Physician's Name & Designation: Name and designation of the physician.
• 24. Physician's Address: Address of the physician.
• 25. Physician's Phone: Phone number of the physician.
• 26. Patient Acknowledgment: Patient's acknowledgment of being examined by the physician.
• 27. Fax: Fax number for submission, if needed.

Failure to submit this form can result in being prohibited from participating in sports or physical activities. It may also delay the process of joining a team or program.

• Ineligibility: You may become ineligible to participate in sports or activities.
• Delayed Participation: Joining a team or program could be delayed.
• Additional Medical Checks: Further medical examinations might be required.
• Administrative Issues: There may be administrative complications.

• 1. School Sports: Submitting before participating in school sports programs.
• 2. Recreational Sports: Needed for joining recreational sports leagues.
• 3. Wellness Programs: Required for fitness or wellness programs.
• 4. Team Memberships: Used to verify eligibility for team memberships.
• 5. Physical Activity Events: Mandated for various physical activity events.