Athlete Medical Referral

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AthleteÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ClassÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Date

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SportÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ CoachÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Dear Physician: The athlete named above must present to the school athletic trainer written permission from a physician to resume participation in athletics. Thank you.

SIGNS, SYMPTOMS, AND IMMEDIATE CARE GIVEN:

____________________________________ÝÝÝÝÝÝÝÝÝÝÝ ________________________________________________

Suspected Injury/IllnessÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Athletic Trainer Signature

Occasion: __________ GameÝ ___________ PracticeÝ _____________OtherÝ Parent contacted: Yes____ No _____

Physician:

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Specific Diagnosis and/or Surgical Procedure

_____________________________ to _______________________________

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Period of Restriction

Prescribed Treatment/Rehabilitation/Programs:

Additional Instructions/Precautions:

Frequency: ______ Daily or _______ days per week for _______ weeks or _______ until program is completed.

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Physician SignatureÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ DateÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Phone