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HPI: Sports Physical
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Front Office Signature
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Pre-Operation Clearance - Name of Surgery
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Date of Planned Surgery
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Social History -
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ROS - Pre-Op Clearance- All NEG
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ever been denied to play sports?
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Surgery?
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Ongoing Medical Conditions?
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Fainted?
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Chest Pain during exercise?
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heart skip a beat/ race during exercise?
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Any Heart Problems?
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EKG or ECHO?
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Seizure?
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Abnormal Shortness of Breath during exercise?
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Unexplained death in family member <50 years
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miss a game due to an injury?
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Broken Bone?
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Joint pain?
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Asthma?
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Missing kidney? spleen?
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Males: do you have a hernia?
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Mono this past month?
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Concussion?
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Blow to head --> h/a or memory loss?
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Numbness or Tingling (EXT)?
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Vision problems? eye injury?
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worry about your weight?
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eating disorder?
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FEMALES ONLY - ever had a period?
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how many periods in the past year?
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Age of your first Period?
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LAST Tdap Vaccination
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Explain "Yes" Answers here
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Vision Right Eye
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Vision Left Eye
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Vision Both Eyes
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Corrected Vision
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Pupils Equal (Yes)/ Unequal (No)
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MA Signature
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Appearance
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HEENT
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Lymph Nodes
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Heart - CV
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Lungs
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Abdomen
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Genitourinary (Males only)
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Skin
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Neuro
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Musculoskeletal
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PE Abnormals - Free write here
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Cleared for Sports (Yes)
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Cleared for Sports (with EXCEPTION)
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Referral
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Not Cleared for Sports
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I have evaluated...
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Pre- Op Clearance PLAN
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Cleared for Surgery
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Name of Physician/ Provider
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