Returning Student Medical Form - EKG Update

Athletic Department

PO Box 265

Paul Smiths, NY 12970

Email: smittynation@paulsmiths.edu

(This document is only required for student athletes who are returning to Paul Smith’s College; all first-year and incoming transfer students are already required to have a medical examination as a new student to the college. Health Services at Paul Smith’s College will have those documents on file.) 

To: Paul Smith’s College Athletic Department

Date: ________________________________

_____________________________________ has completed a sports physical exam on the

(student’s name)

above date. 

A 12-lead EKG was performed on _______________________

(date)

Did the student athlete pass the 12-lead EKG with a normal reading? ______________________

(yes or no)

Does this student have an increased risk of a cardiac event with competitive sport collision

activities? __________________________. If yes, please elaborate:

(yes or no)

_________________________________________________________________________

She/he/they may participate in ___________________________________ and engage in

(name of sport/sports)

strenuous exercise or physical activity. 

___________________________________________

                               (MD signature)

___________________________________________

                                   (Address)

___________________________________________

                              (Phone number)

(MD please note: If the student is NOT cleared for the above sport, please send a note describing the student’s activity limits and the length of time the limits will be in effect.)