Consent and Authorization for Pre-Participation Sports Physical Examination

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Consent and Authorization for Pre-Participation Sports Physical Examination

Student and Parent Information

Nature and Purpose of the Exam

A pre-participation physical evaluation (PPE), commonly called a sports physical, is a medical exam required by schools and athletic associations before a student can participate in organized sports. The exam has two main parts: (1) Medical history: a detailed review of previous illnesses, injuries, surgeries, family heart conditions, and symptoms during exercise. (2) Physical exam: checking height, weight, blood pressure, vision, heart, lungs, abdomen, and joint mobility/strength. The goal is to identify conditions that could place the athlete at risk of injury, illness, or rare cardiac events during sports, and to discuss safe participation.

Critical Cardiac History Screening

[ ] Has the student ever passed out or felt dizzy during or after exercise?
[ ] Has the student ever experienced unexplained chest pain or shortness of breath during exercise?
[ ] Has any family member died suddenly of an unexplained heart condition or before age 50?
[ ] Has a doctor ever told the student they have a heart murmur, high blood pressure, or a heart condition?

Risks and Disclosures

Incomplete screening: a physical exam can find many common health issues but cannot detect all potential medical conditions or prevent all sports-related injuries, including rare congenital heart defects.
Referral required: if abnormal findings are discovered (such as a heart murmur or high blood pressure), clearance will be deferred until the student is evaluated by a specialist (e.g., a pediatric cardiologist).
Information release: the clinic is authorized to release the completed sports clearance form to the school's athletic department. Detailed medical records will remain confidential.

Alternatives to Sports Physical

Exam by regular pediatrician: having the exam done during a comprehensive annual wellness visit at the student's regular doctor's office.
No exam: choosing not to complete the physical, which means the student will not be cleared to participate in school sports.

Authorization to Release Medical Clearance

I authorize the examining provider to share the final clearance status (Cleared / Cleared with restrictions / Not cleared) and the pre-participation clearance form with the designated athletic director, school nurse, or coach at the school named above. Detailed medical notes will not be shared without separate written consent.

Right to Refuse

The parent or legal guardian has the right to refuse any part of the physical exam. If a critical part of the exam (such as checking blood pressure or the heart) is refused, the provider will not be able to sign the sports clearance form.

Parent and Student Understanding

We confirm that we have completed the medical history screening accurately to the best of our knowledge. We understand the purpose and limitations of the sports physical exam. All our questions have been answered.

Language Access

If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form.

Parental Consent and Authorization

I voluntarily authorize the provider to perform a pre-participation sports physical on my child. I confirm all history information is correct. I authorize the release of the clearance form to the school.

Signatures and Verification

Parent or Legal Guardian Signature
Student Athlete Signature (if 12 or older)
Examining Provider Signature
Date and Time of Consent
Document ID: CC-PENDING
CONSENTCOLLECT