Table A1

Periodic Health Examination Form

Physical examination
    Date of examination:________________
MedicalNormalAbnormal (specify)
    Lymph nodes
        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)
    Genitourinary (males only)
        Visual acuity (corrected/uncorrected)
        Equal pupils
        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
12 Lead ECGDetails:
    □ Normal/no changes
    □ Common and training-related ECG changes
    □ Uncommon training-unrelated ECG changes
Blood TestsOther:
    Cholesterol (total)
    LDL cholesterol
    HDL cholesterol
    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: ________________________
Signature of examiner:_________________________Date: ________________