DRAFT 4 39513040

For students requiring more than 3 consecutive days of missed physical activity.
10910 Route 108 Ellicott City, MD 21042 410-313-6600 www.hcpss.org
C. PE Teachers
HCPSS/OSESS/Physical Activity/cmm/3.20.14






Howard County Public School System
Physical Education/Activity Assessment Form

Student: DOB: School:

Physicians Name: Phone Number:
The school nurse may contact the physician if additional information is needed.

Print Parent/Guardian Name: Signature of Parent/Guardian:

BOX 1, 2 AND 3 TO BE COMPLETED BY PHYSICIAN




















CHECK ACTIVITIES THAT SHOULD BE RESTRICTED OR LIMITED












COMMENTS - Additional information that will assist in modifications for physical education/activity for this student. (May attach additional comments.)







Signature of Physician


Physicians Stamp Date
Medical Diagnosis/Injury:

Duration of the condition: Short Term Long Term Permanent

The condition is: Progressive Non-Progressive Part of Body Effected:

Student may return to unrestricted activity by . Next Exam is .

Functional Capacity:
Unrestricted Moderate Restriction
(no restrictions on contact or intensity) (limitation on sustained, strenuous activities)

Self-Limited Severe Restriction
(determine appropriate level of intensity/pace) (limitations are severe)

Mild Restriction Restricting Physical Activity throughout the School Day
(only avoid vigorous activities) (including recess)

Needs to Use: _____Wheelchair _____Crutches _____Ace Wrap _____Splint _____Elevator Other

Locomotor Skills such as run, walk, hop, skip, jump, gallop, leap, etc.

Cardiovascular: Flexibility: Muscular Strength/Endurance:
Aerobic Activity Upper Body Curl Ups
Jump Rope Lower Body Weights
Bicycle Back/Abdominal Pull Ups / Chin Ups
Jog / Run (i.e. mile run) Use of Weights / Weight Machines

Team Sports (i.e. Soccer, Basketball, etc.)
Individual Sports (i.e. Tennis, Bowling, etc.)


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