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 _______________________________

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