B S ABDUR RAHMAN CRESCENT UNIVERSITY, CHENNAI

2017-2018 SPORTS QUALIFYING PHYSICAL EXAMINATION CLEARANCE FORM

FOR ATHLETICS EVENT (800m, 1500m, 5000m and10000m)

I. Personal Details: Student Name: _________________________________

Birth Date: __________ Age:_____ Gender: M / F Blood group:_____________

Address:___________________________________________________________

__________________ Mobile _________________ School:__________________

_______________________ Sports/ Event: ___________________________

II. Developmental Status:

Chronological age: _________ years _________ months

Training age: ___________ years _________ months

Height: ________ Weight:_________

III. Current Fitness Assessment (conducted on the day of trials)

i) FLEXIBILITY

Poor Excellent
1 2 3 4 5 Comments
Hip flexors
Hamstrings
Calves

ii) STRENGTH ENDURANCE:

Exercise Score (number of repetitions)
Push-up
Curl-up
Chin-up (unassisted)
Dip (unassisted)
iii) TECHNIQUE:

Poor Excellent
1 2 3 4 5 Comments
Upper-body posture

Arm action

Foot strike

Action of the leg joint on

landing

Knee lift

iv) Aerobic power:

Longest continuous aerobic run from previous macrocycle (season): 3,000m / 5000m time trial:
_____________

v) ANAEROBIC FITNESS AND SPEED

Time trial distance Time

60 meters
100 meters
400 meters

vi) RACE-SPECIFIC PHYSICAL FITNESS

Time trial distance Time

vii) RACE-SPECIFIC MENTAL FITNESS:

Poor Excellent
1 2 3 4 5 Comments
Motivation

Confidence

Concentration

Ability to relax

Pacing skill

Tactical skill
IV. Racing History:
Previous record
Event Time Date Meet/ event Comments

400 meters

800 meters

1,500 meters

3,000 meters

5,000 meters

10,000 meters

Half marathon

Marathon

V. Health History

Type of injury, illness, Period of injury, illness,

or medical concern or medical concern Comments

 Requires further evaluation before a final recommendation can be made:

______________________________________________________________________

 Cleared/ not cleared: ____________________________________________________

 Reason: _______________________________________________________________

Signature of:

Student Coach Director of Physical Education