Edit Mississippi Sports Medicine Athletics Physical Here

Official Mississippi Sports Medicine Athletics Physical Form in PDF

The Mississippi Sports Medicine Athletics Physical form is a crucial document designed for students wishing to participate in athletic activities. This form collects essential medical history and personal information to ensure the safety and well-being of young athletes. Parents and guardians are encouraged to fill out the form accurately to facilitate a comprehensive physical screening.

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Edit Mississippi Sports Medicine Athletics Physical Here

Outline

The Mississippi Sports Medicine Athletics Physical form is a crucial document designed for student-athletes participating in school sports. It serves multiple purposes, primarily ensuring that each athlete is medically cleared to engage in physical activities safely. The form collects essential personal information, including the athlete's name, date of birth, school, grade, and the specific sport(s) they intend to participate in. Additionally, it requires details about the parent or guardian, including contact information and the family physician's name. A significant aspect of the form is its comprehensive medical history section, which inquires about any family medical conditions, previous injuries, and the athlete's own medical history. This includes questions about heart conditions, respiratory issues, and any surgeries or hospitalizations. Furthermore, the form includes a waiver acknowledging that the physical examination is limited and does not guarantee the prevention of injuries. Lastly, the physician's section provides space for the medical professional to record the athlete's height, weight, and vital signs, along with an assessment of their overall health and fitness for participation in sports. This thorough approach aims to prioritize the health and safety of student-athletes, ensuring they are fit to compete while also protecting the medical providers involved.

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Common mistakes

Filling out the Mississippi Sports Medicine Athletics Physical form requires careful attention to detail. One common mistake is failing to provide complete and accurate personal information. Individuals often overlook sections such as the athlete's date of birth or Social Security Number. Incomplete information can lead to delays in processing the form and may affect the athlete's eligibility to participate in sports.

Another frequent error occurs in the family medical history section. Many people do not fully understand the importance of this section and may leave it blank or provide vague answers. For example, if a family member has experienced heart disease or diabetes, it is crucial to specify who it was. This information is essential for medical professionals to assess any potential risks associated with the athlete's health.

In the athlete’s orthopaedic history section, individuals sometimes fail to disclose past injuries or surgeries. Omitting this information can have serious consequences. If an athlete has had a significant injury, it is vital for medical professionals to know in order to provide appropriate care and avoid exacerbating any existing conditions.

Additionally, many individuals neglect to mention any current medications in the medical history section. Whether prescription or over-the-counter, this information is important for the physician to consider during the evaluation. Not disclosing medications can lead to potential interactions or complications during treatment.

Another mistake is related to the signature section. Parents or guardians may forget to sign the form, especially if the athlete is underage. A missing signature can render the form invalid, which could prevent the athlete from participating in sports until the issue is resolved.

Lastly, individuals often overlook the importance of reviewing the entire form before submission. Errors in spelling or incorrect information can lead to misunderstandings or delays. Taking the time to double-check the form ensures that all information is accurate and complete, facilitating a smoother process for the athlete.

Form Preview Example

DO NOT FOLD FORM

UNIVERSITY OF MISSISSIPPI MEDICAL CENTER/UNIVERSITY SPORTS MEDICINE

ATHLETIC PARTICIPATION FORM

Please Print

Name __________________________________________________________________________________ Date ____________________________

School _______________________________________________________ Grade ___________ Sport(s) __________________________________

Sex: M F Date of Birth ______________________________ S.S.N. __________________________________________________ Age ________

Parent/Guardian Name __________________________________________________________________ Work Phone ________________________

Address _____________________________________________________________________________ Home Phone ________________________

Family Physician _______________________________________________________________________ Work Phone ________________________

			FAMILY MEDICAL HISTORY
			Has any member of your family under age 50 had these conditions?
Yes	No	Condition	Whom
		Heart Attack	___________________________________________________________________________
		Sudden Death	___________________________________________________________________________
		Stroke	___________________________________________________________________________
		Heart Disease / High Blood Pressure ___________________________________________________________________________
		Diabetes	___________________________________________________________________________
		Sickle Cell Anemia	___________________________________________________________________________
		Arthritis	___________________________________________________________________________
		Epilepsy	___________________________________________________________________________
		Kidney Disease	___________________________________________________________________________
			ATHLETE’S ORTHOPAEDIC HISTORY
			Has the athlete had any of the following injuries?
Yes	No	Condition	Date	Yes	No	Condition	Date
		Shoulder L / R	_____________________			Neck Injury / Stinger	____________________
		Elbow L / R	_____________________			Arm / Wrist / Hand L / R	____________________
		Hip	_____________________			Back	____________________
		Knee L / R	_____________________			Thigh L / R	____________________
		Chronic Shin Splints L / R	_____________________			Lower Leg L / R	____________________
		Foot L / R	_____________________			Ankle L / R	____________________
		Pinched Nerve	_____________________			Severe Muscle Strain	____________________
						Chest	____________________

Previous Surgeries: ________________________________________________________________________________________________________

ATHLETE’S MEDICAL HISTORY

Has the athlete had any of these conditions?
Yes	No	Condition	Yes	No	Condition	Yes	No	Condition
		Heart Murmur			Organ Loss			Overnight in hospital
		Seizures			Shortness of breath / coughing			Hernia
		Kidney Disease			during exercise			Rapid weight loss / gain
		Irregular Pulse			Chest Pain/Tightness			Take supplements / vitamins
		Single Testicle			Loss of consciousness/"Knocked out"			Heat related problems
		High Blood Pressure			Heart Disease			Menstrual irregularities
		Dizzy / Fainting			Diabetes			Recent Mononucleosis /
		Head Injury / Concussion			Liver Disease			Enlarged Spleen
		Asthma			Tuberculosis

 Have you had any serious medical illness/injury since your last sports physical? _____________________________________________

 Are you currently taking any prescription or non prescription (over the counter) medicaitons? ___________________________________

 Surgery - What Type? ___________________________________________________________________________________________

 Allergies (Food, Drugs) __________________________________________________________________________________________

Date of last Tetanus Immunization ____________________________________________________________________________________________

To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals provid- ing services may be immune from liability under Mississippi Law.

WAIVER FORM

This waiver, executed this ________ day of ___________________, 20____, by ______________________________________________ , M.D.

and ________________________________________, patient, is executed in compliance with Mississippi law, with the full understanding that if a phy-

sician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.

__________________________________________________					_________________________________________________________________
Signature of Patient					Typed or Printed Name of Physician
__________________________________________________					_________________________________________________________________
Signature of Parent/Guardian (Not required if patient is over 18 yrs old.)					Signature of Physician
			INFORMATION BELOW TO BE FILLED OUT BY PHYSICIAN ONLY
Height ______________________			Weight ____________________ Blood Pressure __________________ Pulse ____________________________
ORTHOPAEDIC EXAM				GENERAL MEDICAL EXAM
		Norm	Abnl			Norm	Abnl		Norm	Abnl
I.	Spine / Neck	________	________	ENT		________	________	Lungs	________	________
	Cervical	________	________	Heart		________	________	Abdomen	________	________
	Thoracic	________	________	Skin		________	________	Hernia (if Needed) ________		________
	Lumbar	________	________	General Health Comments ____________________________________________________
II.	Upper Extremity	________	________	__________________________________________________________________________
	Shoulder	________	________	__________________________________________________________________________
	Elbow	________	________	FLEXIBILITY		LEFT	RIGHT	FLEXIBILITY	LEFT	RIGHT
	Wrist	________	________	Neck		________	________	Shoulders	_________	________
	Hand / Fingers	________	________	Hips		________	________	Quadriceps	________	________
III.	Lower Extremity	________	________	Hamstrings		________	________	Achilles	________	________
	Hip	________	________	Back Ext / Flex		________	________
	Knee	________	________	Comments _________________________________________________________________
	Ankle	________	________	__________________________________________________________________________
	Feet	________	________	__________________________________________________________________________

Other Comments __________________________________________________________________________________________________________

OPTIONAL EXAMS
DENTAL	VISION L ________ R ________
Comments ___________________________________________	Comments: ____________________________________________________
____________________________________________________	_____________________________________________________________

Comments _______________________________________________________________________________________________________________

[	]	From this limited screening I see no reason why this student cannot participate in athletics
[	]	Student needs further evaluation as described

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