Sports Physical Form
Bring the physical form filled out and signed by your parent or guardian (available from school office). No exam will be allowed unless signed by a
parent. Be sure immunization updates are noted on form (especially last tetanus and MMR). No immunizations can be administered at this time.
These are sports physicals and do NOT take the place of a comprehensive physical. No immunizations will be given.
The form must be filled out and turned in before students may participate in athletics. Includes required CONCUSSION information that must be filled out.
Please download and sign the forms below and return them to your school.
Iowa Concussion Legislation
Effective July 1, 2011, Iowa law requires that students in grades 7 – 12 who participate in extracurricular interscholastic activities, cheerleading and dance; and their parents/guardians; must sign a copy of the acknowledgement form found below and return it to their school.
Students cannot practice or compete in those activities until this form is signed and returned.
In addition, please note this important information from Iowa Code Section 280.13C, Brain Injury Policies:
- A child must be immediately removed from participation (practice or competition) if his/her coach or a contest official observes signs, symptoms, or behaviors consistent with a concussion or brain injury in an extracurricular interscholastic activity.
- A child may not participate again until a licensed health care provider trained in the evaluation and management of concussions and other brain injuries has evaluated him/her and the student has received written clearance from that person to return to participation.
- Key definitions:
- “Licensed health care provider” means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.
- “Extracurricular interscholastic activity” means any extracurricular interscholastic activity, contest, or practice, including sports, dance, or cheerleading
Students participating in sport competitions are required to have a physical examination so the student may safely engage in athletic competition. An Iowa Athletic Pre-Participation Physical Examination Form and Concussion Form must be completed and returned to the Activities Office prior to any participation in athletics.
The following offices will conduct sports physicals for Ankeny and Ankeny Centennial High School students during the following times. No appointment is necessary. Please take a physical form with patient portion completed to the clinic.
UnityPoint Family Medicine Clinic - Ankeny Medical Park
3625 N Ankeny Blvd., Suite F
July 31, 2018: 8:00am-11:00am
August 8, 2018: 4:00pm-7:00pm
The cost of the sports physical is $39 per student. UnityPoint will not submit claims to your insurance company for these services. Payment must be made at the time of service.
225 SE Oralabor Rd., Suite #7
July 31, 2018: 1:00pm-2:30pm
August 2, 2018: 1:00pm-2:30pm
The cost of the sports physical is $30 per student. Naig Chiropractic will not submit claims to your insurance company for these services. Payment must be made at the time of service.
Naig Chiropractic will also perform sports physicals for students who make appointments outside of the scheduled walk-in times. You may make an appointment with the office by calling 515-963-7675.