Table A1

Periodic Health Examination Form

Physical examination
    Date of examination:________________
MedicalNormalAbnormal (specify)
    Appearance
    Eyes/ears/nose/throat
    Hearing
    Lymph nodes
    Heart
        Rhythm
        Heart sounds/murmurs in supine and standing
        Peripheral oedema
        Physical stigmata of Marfan syndrome
    Blood vessels
        Peripheral pulses
        Delay in femoral pulses
        Vascular bruits (femoral)
        Varicose veins
    Blood pressure in sitting position (after 5 min rest)
        Right arm
        Left arm
    Heart rate (after 5 min rest)
    Lungs
    Abdomen
    Genitourinary (males only)
    Skin
    Eyes
        Visual acuity (corrected/uncorrected)
        Equal pupils
    Dental
        DMF index  =  number of decayed, missing or filled teeth:_______
        Oral hygiene assessment: □ Good □ Fair □ Poor
        Visible oral infection: □ No □ Yes
        Presence of worn, broken or loose/mobile teeth: □ No □ Yes
        Dental appliances (bridge, plate, braces or orthodontic appliance): □ No □ Yes
Musculoskeletal
    Neck
    Back
    Shoulder/arm
    Elbow/forearm
    Wrist/hand/fingers
    Hip/thigh
    Knee
    Leg/ankle
    Foot/toes
Investigations
12 Lead ECGDetails:
    □ Normal/no changes
    □ Common and training-related ECG changes
    □ Uncommon training-unrelated ECG changes
Blood TestsOther:
    Haemoglobin
    Haematocrit
    Erythrocytes
    Thrombocytes
    Leukocytes
    Ferritin
    Sodium
    Potassium
    Creatinine
    Cholesterol (total)
    LDL cholesterol
    HDL cholesterol
    Triglycerides
    Glucose
    C-reactive protein
Clinical evaluation outcome
1The athlete does not present apparent clinical contraindications to practice the following sport(s) (specify): No □ Yes □
If the answer to question 1 is “No”, it is recommended that the athlete:
avoids participating:

  • in training (explain)

No □ Yes □

  • in competition (explain)

No □ Yes □
respects the following restrictions:

  • during training (specify)

No □ Yes □

  • during competition (specify)

No □ Yes □
undergoes further examinations (specify):
Examining physician
    Name:________________________Phone number: ________________________
    Address:________________________Email:____________________________
________________________
________________________
Signature of examiner:_________________________Date: ________________