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Pcma 3

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137 views

Pcma 3

Uploaded by

sumeshanjali84
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AIFF -- PRE-COMPETITION MEDICAL ASSESSMENT (PCMA-3)

Name_______________________________ Age_______________ Sex____________

City_____________________________ State____________________ Phone_____________________

Email_________________________________________ Height___________ Weight_______________

Complete this form (including signatures) before your examination. Include dates of any problems and
explain all “Yes” answer below

Yes No
1. Are you currently under a doctor’s care for any reason
2. Have you ever been hospitalized
3. Have you ever had surgery?
4. Are you currently taking any medication or pills?
5. Do you have any allergies (medicines, bee stings etc)?
6. Have you ever been dizzy or fainted during or after exercise?
7. Have you ever had chest pain during or after exercise?
8. Have you ever had high blood pressure
9. Have you ever been told that you have heart murmur
10. Have you ever had racing of your heart or skipped heartbeats?
11. Have you ever had a head injury?
12. Have you ever been knocked out or unconscious
13. Have you ever had a seizure?
14 Have you ever had a stinger or pinched nerve?
15 Have you ever been dizzy or passed out in the heat?
16 Do you have trouble breathing during or after exercise?
17 Do you have any skin problems, itching, rashes etc?
18. Have you ever had any problems with your eyes or vision
19. Do you wear glasses or contacts or protective eye wear?
20. Do you use any special equipment (splints, neck rolls, mouth guards, etc)
21. Has anyone in your family died of heart problems or sudden death before age 50?
22. Do you have only one working organ of usually paired organs (only one eye, kidney
etc
23. Have your ever sprained, broken, dislocated or had repeated swelling or pain of
any bones or joints (Head, Neck, Chest, Shoulder, Back, Hand, Wrist, Elbow,
Forearm, Hip, Thigh, Knee, Ankle, Shin/Calf, Foot)
24. Are any of the above bothering you currently?
25. Have you had any other medical problems? (Asthma, mono, diabetes, etc)
26. Have you had any other medical problems or injuries since your last evaluation?
27. Any special instructions or precautions?
28. When was your last tetanus shot? Date _____________________

Explain all "Yes" answers by question number and indicate dates for each item (include any special
instructions):

______________________________________________________________________________________

______________________________________________________________________________________
I/We hereby state that, to the best of my/our knowledge, the answers to the above questions are correct.

I/We understand that by performing this examination, the undersigned physician does not assume
responsibility for the medical care of this individual:

Signature of Player: ____________________________________________ Date_______________

Signature of Parent or Guardian (if player is under 18)_________________ Date_______________

___________________ONLY A REGISTERED DOCTOR TO WRITE BELOW THIS LINE__________________

Blood HEENT Skin Heart Lungs Abdomen Musculoskeletal ECG Echocardiography


Pressure

NORMAL

ABNORMAL

While this does not constitute a complete physical examination nor replace the need for periodic health
evaluation by a family physician, this individual appears to be physically capable of participation in sports
as of this date, except as indicated below.

☐ Clear for sports without restrictions

☐ Cleared with the following restrictions:_________________________________________

☐ Cleared after completing evaluation/rehabilitation for:_____________________________

☐ Not Cleared_______________________________________________________________

At this player's screening exam the following is/are noted:


Condition/Sign/Symptoms with Simple Explanation/Recommendations

☐ Evaluated (High) Blood Pressure, increase in pressures in the artery during the beating and resting
heart. Maximum normal (age group)
Heart Murmur, Flow of blood through the heart which is audible. In this case, it is
☐ 'Functional' (normal) ☐ Abnormal
☐ Asthma, Blockage of Small airways in the lung. ☐ Use inhaler as prescribed and 30 min before exercise.
☐ Allergic Reactions to stings. Whole body swelling & shortness or breath when stung or bitten.
Epinephrine injector should be available at all times.
☐ Diabetes, Abnormal sugars and sugar metabolism. Continue close monitoring with M.D.
☐ Scoliosis Curvature of the spine. Continue close monitoring with M.D.
☐ Orthopedic Problems being seen by M.D. for this condition.
☐ Should be cleared for play by M.D.
☐ Other____________________________________

Examining Physician's Name___________________ Physician's Signature & Stamp ________________

Physician’s Registration No. ______________________

Date______________

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