Athlete Evaluation Forms
Athlete Evaluation Forms should be clearly defined including its intended design, implementation, outputs and outcomes, it is essential to analyzing success and failure. The athlete evaluation forms may provide information on how to improve program design, or intended to assess the extent to which the individual achieves the intended performance outcomes.
Athlete Evaluation Form: Non-Template
Page Contents
Athlete Evaluation Form: Example
| Name: | Age: | Sport(s): |
| Date of birth: | CLU Class (circle): FR SO JR SR Other | Sex (circle): M / F |
| Address: | Phone: | |
| Personal Physician: | Phone: | |
| In case of emergency, contact: | ||
| Name: | Relationship: | |
| Phone (H) | (W) | (C) |
| Circle “Yes” or “No” for every question (use a pen).Explain all “Yes” answers below. | ||
- Has a doctor ever denied or restricted your participation in sports for any reason? Yes No
- Do you have any ongoing medical condition? Yes No
- Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills? Yes No
- Do you have allergies to medicines, pollens, foods, or stinging insects? Yes No
- Have you ever passed out or nearly passed out DURING exercise? Yes No
- Have you ever passed out or nearly passed out AFTER exercise? Yes No
- Have you ever had discomfort, pain, or pressure in your chest during exercise? Yes No
- Does your heart race or skip beats during exercise? Yes No
- Has a doctor ever told you that you have:
(circle all that apply)
High blood pressure A heart murmur
High cholesterol A heart infection Yes No - Has a doctor ever ordered a test for your heart? (i.e., ECG, EKG, echocardiogram) Yes No
- Has any one in your family died for no apparent reason? Yes No
- Has any family member or relative died of heart problems or of sudden death before age 50? Yes No
- Does anyone in your family have Marfan syndrome? Yes No
- Have you ever spent the night in a hospital? Yes No
- Have you ever had surgery? Yes No
- Has a doctor ever told you that you have asthma or allergies? Yes No
- Do you cough, wheeze, or have difficulty breathing during or after exercise? Yes No
- Is there anyone in your family who has asthma? Yes No
- Have you ever used an inhaler or taken asthma medicine? Yes No
- Were you born without or are you missing a kidney, an eye, a testicle, or any other organ? Yes No
- Have you had infectious mononucleosis (mono) within the last month? Yes No
- Do you have any rashes, pressure sores, or other skin problems? Yes No
- Have you had a herpes skin infection? Yes No
- Have you ever had a head injury or concussion? Yes No
- Have you been hit in the head and been confused or lost your memory? Yes No
- Have you ever had a seizure? Yes No
- Do you have headaches with exercise? Yes No
- Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? Yes No
- Have you ever been unable to move your arms or legs after being hit or falling? Yes No
- When exercising in the heat, do you have severe muscle cramps or become ill? Yes No
- Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? Yes No
- Have you had any problems with your eyes or vision? Yes No
- Do you wear glasses or contact lenses? Yes No
- Do you wear protective eyewear, such as goggles or a face shield? Yes No
- Are you unhappy with your weight? Yes No
- Are you trying to gain or lose weight? Yes No
- Has anyone recommended you change your weight or eating habits? Yes No
- Do you limit or carefully control what you eat? Yes No
- Do you have any concerns that you would like to discuss with your doctor? Yes No
FEMALES ONLY
- Have you ever had a menstrual period? Yes No
- How old were you when you had your first period?
- 43. How many periods have you had in the last 12 months?
**Explain all “Yes” answers here and list answers by their corresponding numbered question:
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct and I agree to update information as needed based on current circumstances. Parent must sign if athlete less than 18 years old.
Signature of athlete ______________________________________ Date _________
Signature of parent/guardian______________________________________ Date _________
Printed name of parent/guardian______________________________________
Name ___________________Sport(s)_____ Sex_______ Date of birth____________
After reviewing History Form: Follow-up Questions on More Sensitive Issues
- Do you feel stressed out or under a lot of pressure? Yes No
- Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days? Yes No
- Do you feel safe? Yes No
- Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke? Yes No
- During the past 30 days, did you use chewing tobacco, snuff, or dip? Yes No
- During the past 30 days, have you had at least 1 drink of alcohol? Yes No
- Have you ever taken steroid pills or shots without a doctor’s prescription? Yes No
- Have you ever taken any supplements to help you gain or lose weight or improve your performance? Yes No
BP (left arm, sitting)___________ Height____________ Weight________ Pulse _____
Hgb (females only)__________g/dL Vision R 20/_____ L 20/_____ Corrected: Y N Pupils (circle): Equal Unequal
| *HEALTHCARE PROVIDER- please review Page 1: History Form before performing physical exam.* | ||
|---|---|---|
| Normal | Abnormal Findings | |
| Appearance | ||
| Eyes/ears/nose/throat | ||
| Hearing | ||
| Lymph nodes | ||
| Heart (including murmurs) | ||
| Pulses | ||
| Lungs | ||
| Abdomen | ||
| Genitourinary/hernias | ||
| Skin | ||
| Musc./Skeletal: Neck | ||
| Back | ||
| Shoulder/arm | ||
| Elbow/forearm | ||
| Wrist/hand/fingers | ||
| Hip/thigh | ||
| Knee | ||
| Leg/ankle | ||
| Foot/toes | ||
| Lab: Sickle cell screen | (must attach copy of lab result to form) | |
(check off)
___ Cleared without restriction
___ Cleared, with recommendations for further evaluation or treatment for:____________________________________
___ Not cleared for (circle): All sports or Certain sports:____________________________________
Reason:____________________________________
Recommendations/notes:____________________________________
IMMUNIZATIONS (Tetanus, MMR, Hepatitis B- required; Polio Hepatitis A, Varicella, Meningococcal, HPV- recommended)
Please check patient’s immunization status and give required immunizations if possible. Patient can be provisionally cleared without required immunizations as CLU Health Services will provide required immunizations for a charge if patient is not up to date.
Name of physician, PA-C, or NP (print)____________________________________ Date of exam ________________
Address____________________________________ Phone _____________________
City____________________________________ State________________Zip Code______________________
By signing below you confirm that you have reviewed the History Form and examined the patient as indicated above.
Signature of physician,PA-C,or NP____________________________________ Date_____________
Name ________________________________Sex_________Date of birth______________
Sport(s)____________________________________
* Athlete, please complete questions 1, 2, 3, and 4 *
1. Do you have medical insurance other than the student insurance (circle “Yes” of “No”)? Yes No
If yes, you must attach a copy of the front and back of your insurance card to these forms.
2. Please fill out the following (circle “Yes” or “No” and explain below):
a) Have you ever had an injury, like a sprain, muscle, or ligament tear or tendinitis,
that caused you to miss a practice or game: If yes, indicate the affected area below: Yes No
b) Have you had any broken or fractured bones, or dislocated joints? If yes, indicate below: Yes No
c) Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections,
rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, indicate below: Yes No
d) Have you ever had a stress fracture? If yes, indicate below: Yes No
e) Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?
If yes, indicate below: Yes No
f) Do you regularly use a brace or assistive device? If yes, indicate below: Yes No
g) Have you had any type of head trauma, including concussion, within the last 12 months?
If yes, indicate below: Yes No
3. Place a check mark next to body parts affected and specify right (R) or left (L); then explain below.
_____Head _____Neck _____Shoulder _____Upper arm _____Elbow
_____Forearm _____Wrist _____Hand _____Fingers _____Chest
_____Spine/back _____Hip _____Thigh _____Knee _____Calf/shin
_____Ankle _____Foot _____Toes _____Other
4. Explain:____________________________________
____________________________________
____________________________________
* Below is to be filled out ONLY by Athletic Staff Personnel. *
No outside medical provider signature or examination will be accepted.
TRAINING ROOM (Athlete must go to Athletic Trainers for this section)
Date:_________ Body fat: Bi _____ Tri _____ SC _____ IC _____ Trainer’s Initials_________
……………………………………………………………………………………………………..
ORTHOPEDICS CLEARANCE: The following is to be completed only by a Team Physician
Notes:____________________________________
(check off)
___ Cleared without restriction
___ Cleared, with recommendations for further evaluation or treatment for:____________________________________
___ Not cleared. Reason____________________________________
Physician Name (print):
Signature of physician:____________________________________Date:____________________________________
Assumption of Risk Statements
Name:____________________________________
Statement of Insurance Coverage:
Sports activities have varying degrees of risk of injury which participants should recognize by the nature of the activity.Students who participate in the intercollegiate sports program must show proof of personal health insurance that covers intercollegiate athletic injuries. If a student has a plan in their name or a plan through a parent’s insurance, this will act as their primary insurance. The athletic department also has a limited athletic insurance policy for all participants that helps to cover expenses incurred in excess of the student’s primary insurance. This policy covers only injuries that occur during official practice or games of the sport in which the athlete is participating and may exclude pre-existing conditions. Should an injury occur, you must report this to a certified athletic trainer. You must have an injury report on file and a claim form completed by a certified athletic trainer. Health Services will discuss your options for medical care on an individual basis and will assist students in accessing appropriate medical care. If there is a remaining balance due after your insurance has paid for your treatment, Health Services will guide students through submitting claims to the athletic insurance carriers. No bills are “paid automatically.” It is the student’s responsibility to ensure that bills are paid in a timely manner.
Authorization: I have read and understand the information above. I hereby authorize any hospital, physician or other person who had attended or examined or has in his possession records pertaining to my care, to furnish current athletic insurance company or its representatives, any and all information with respect to any illness or injury, medical history, consultation, prescriptions, or treatment, and copies of all hospital or medical records and all other information requested. It is agreed that all medical and/or hospital expenses incurred beyond those covered by any applicable insurance policy will be paid directly and promptly by the undersigned student and parents or guardians, and the athletic department will not be responsible thereon. A photocopy of this authorization shall be considered as effective and valid as the original.
Signature:____________________________________Date:______________
Parent/Guardian Signature: (if minor)____________________________________ Printed name_______________
Assumption of Risk:
I fully understand that while playing or practicing to play/participate in intercollegiate athletics serious injuries can occur, such as head, neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to virtually all internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, and serious injury or impairment to other aspects of my body, general health and well-being. I understand that the dangers and risks of playing and practicing to play/participate in intercollegiate athletics may not only result in serious injury, but in a serious impairment of my future abilities to earn a living, to engage in other business, social, and recreational activities, and generally to enjoy life. As a participant, I knowingly accept this risk. Because of the dangers of participating in athletics, I recognize the importance to follow the coaches’ and trainers’ instructions regarding playing techniques, training and other team/game rules, and agree to abide by such instructions.
Signature:_____________________________________Date:____________
Parent/Guardian Signature: (if minor)_______________________________Date:______________
FOOTBALL ONLY: I also understand that while participating in football it is a violation of the football rules to use the helmet, which I am wearing, to butt, ram, or spear an opposing player, teammate or object, and such use can result in severe head or neck injury, paralysis or death to me as well as possible injury to an opponent or teammate. Also, I understand that no helmet can prevent all head and neck injuries that I might receive while participating in football.
Signature:______________________________Date:______________
Parent/Guardian Signature: (if minor)_______________________ Date:________________________
Emergency Medial Consent:
I give athletic coaches and Sports Medicine Staff (i.e., Certified Athletic Trainers, team physician, paramedics, or emergency room physicians) as our agent(s), permission to consent to and administer emergency medical treatment in the event of a serious or life-threatening injury. This consent includes any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is rendered under the general or special supervision of any physician and surgeon licensed hospital, whether such examination, diagnosis, treatment, or hospital care being required and gives our agent(s) the authority and power to give specific consent to any and all such examinations, diagnosis, treatment, or hospital care which the physician in his/her best judgment may deem advisable. Information collected on this form is used for the purpose of determining medical status. Information on this form, as well as medical information collected throughout the school year pertaining to the practice and play of intercollegiate athletics, will be reviewed by Health Services staff as well as the Athletic Trainers and Team Orthopedist. I authorize Athletic training, the Team Orthopedist, and Health Services to review and discuss medical information as necessary to establish medical clearance to participate in Intercollegiate Athletics. Medical information not directly related to my medical clearance will not be discussed unless specifically authorized by me. I understand that information will not be shared with individuals not listed above, without my consent.
Signature: _____________________________________Date:______________
Parent/Guardian Signature: (if minor)______________________________Date:________________
Athlete Performance Review – Athlete Information | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Name Of Athlete: | Birth Date: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Date: | Class: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Review Guidelines | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Complete this assessment using the following scale: NA = Not Applicable 1 = Unsatisfactory (poor performance, attitude, individual) 2 = Needs Improvement (poor but has potential) 3 = Satisfactory (average ability) 4 = Good (above average ability) 5 = Excellent (top 5%)
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Evaluation / Comments | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Evaluator Name: ______________________________________
Evaluator Position: ____________________________________
Evaluator Signature: _________________________________________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Participation: use the following to assign participation marks to each student athlete.
The following are components of excellent participation that must be considered in the selection of the athletes for this award:
ü Regular attendance at all practices and games
ü Co-operates with coaches, fellow players, officials and other teams
ü Has consistent and determined effort
ü Appropriate behaviour on busses, at other schools, and at home games
ü Has a positive and enthusiastic attitude
ü Reliable in meeting teacher and coach expectations
Based on the above components of participation and the criteria listed below, coach assigns each student athlete a participation point value to be circled on this page.
10 points: excellent participation – ALWAYS meets all criteria, never absent or late
9 points: very good participation – no more than 1 absence or late
8 points: good participation
7 points: above average participation
6 points: average participation
0-5 points: below average to well below average participation
Skill: use the following to assign skill marks to each student athlete.
The following are components of excellent skills that must be considered in the selection of the athletes for this award:
ü Appropriate fitness level
ü Knowledge of the sport
ü Performance of specific skills for the individual sport
ü Appropriate reaction to competitive situations
Based on the above components of skill and the criteria listed below, coach assigns each student athlete a skill point value to be circled on this page.
10 points: excellent skill level (could make a provincial all-start team)
9 points: very good skill level (could be a “starter” on the top teams in the province)
8 points: good skill level (could start on any team in the Fraser Valley League)
7 points: above average skill level (starts regularly on the school team)
6 points: average skill level
0-5 points: below average to well below average skill level
Athlete Evaluation Forms Purpose
Each of the athlete evaluation forms should have a primary purpose around which it can be designed and planned, although it may have several other purposes. It is a common problem in athlete evaluation studies that they are expected to be all things to all people, whereas the reality is they have limited resources and thus should only focus on a limited range. Athlete evaluation studies which are too much of a shotgun approach are unlikely to adequately address the needs of any stakeholders.