PHYSICAL EXAMINATION UPDATE
(Statement For Continued Participation)
Name Phone
Address
Street City State Zip
School Grade 8 9 10 11 12
(circle one)
WIAA Regulation – PHYSICAL EXAMINATION – Prior to the first practice for participation in interscholastic athletics in a middle level school and prior to participation in a high school, a student shall undergo a thorough medical examination and be approved for interscholastic athletic competition by a medical authority licensed to perform a physical examination. This physical examination must include, but not necessarily be limited to:
A. Documentation of a detailed review of the student’s medical history with special attention to presence or absence of cardiovascular/pulmonary risks and/or previous significant injury and rehabilitation therefrom.
B. Documentation of satisfactory examination of the cardiopulmonary system.
C. Documentation of satisfactory sport specific orthopedic screening examination.
D. A written statement by the examiner as to the fitness of the student to undertake the proposed athletic participation, together with suggestion for activity modification if necessary.
*******************************************************
EXAMINER’S CERTIFICATION:
Date of last complete physical examination _____
I hereby certify that the above-named individual’s physical condition is adequate to participate in supervised interscholastic activities NOT CROSSED OUT BELOW:
BASEBALL BASKETBALL CROSS COUNTRY DANCE/DRILL FOOTBALL GOLF GYMNASTICS SOCCER SOFTBALL SPIRIT SWIMMING TENNIS TRACK VOLLEYBALL WRESTLING Other
Date Examiner’s Signature
Examiner’s Name (Print)
MEDICAL AUTHORITIES LICENSED TO GIVE
PHYSICAL EXAMINATIONS
1. Medical Doctor (MD) 4. Medics – Physician Assistant (P.A.)
2. Doctor of Osteopathy (D.O.) 5. Naturopaths (N.D.)
3. Certified Nurse Practitioner (CRN)