Clinical Reference Systems: Pediatric Advisor 10.0
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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