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Get FCPS Medical Evaluation for Continued Participation in Physical Education Referral for Illness and Injury

DO, LNP, PA) Medical diagnosis: Date student will be re-examined or may return to unrestricted activity: Please indicate the student’s ability to participate in the types of activities listed below: For student diagnosed with concussion, please complete page 2. All Grade Levels Running/sprinting Jogging Walking Dance Jumping Balancing (1 or 2 feet) Balancing (inverted) Resistance Bands (upper body) Resistance Bands (lower body) Cardiovascular equipment (bike, elliptical) YES YES YES NO NO N.

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