Sports Physical

Individual Patient Pricing

Service Tier	Who It's For	What's Included	Price
Standard Sports Physical	Grades K – 8	FHSAA EL2 form completion, full musculoskeletal & cardiovascular exam, provider sign-off & clearance letter	$75 – $99
Premium Physical + 12-Lead EKG	Grades 9 – 12	Everything above PLUS in-office 12-lead EKG, interpretation, & FHSAA cardiac clearance documentation	$150 – $199
Complete Athlete Package	Performance Athletes	Premium physical + EKG + wearable analytics consult + personalized performance & injury prevention review	$249 – $349

School & Team Bulk Pricing

Package	Minimum	Details	Rate / Athlete
On-Site School Screening Day	25+	G2G provider travels to campus: physical + EKG per athlete: same-day results & clearance	$85 – $95
Charter School Partnership	Seasonal	Dedicated G2G provider, priority scheduling: branded clearance documents: school liaison coordination	Custom Quote
Club / Travel Team	10+	In-office group block; FHSAA clearance per athlete; parent portal-ready documentation	$95 – $100

Why Choose Good to Great?

✓ Board-Certified Provider

✓ FHSAA EL2 Documentation

✓ 12-Lead EKG Included

✓ Same Day Clearance

✓ Orlando & Tampa FL

✓ On-Site Team Screenings

SECTION 1 — STUDENT / ATHLETE INFORMATION

First Name:

First Last Name:

Date of Birth:

Age

Grade

Gender(Required)

Male

Female

Other

School Name

School District

Sport(s)

Academic Year

Home Address

Street Address City County / State / Region ZIP / Postal Code

Parent / Guardian Name

Relationship

Parent Phone

Emergency Contact Phone

Insurance Carrier

Policy #

SECTION 2 — PERSONAL & FAMILY MEDICAL HISTORY

(To be completed by Parent/Guardian)

Has the athlete ever had or been told they have any of the following?

CARDIAC / CARDIOVASCULAR HISTORY

Chest pain, tightness, or pressure during exercise

Yes

Fainting or near-fainting during or after exercise

Yes

Unexplained shortness of breath during normal activity

Yes

Heart palpitations, racing, skipping, or irregular heartbeat

Yes

High blood pressure or high cholesterol

Yes

A heart murmur (detected at birth or later)

Yes

Kawasaki disease or rheumatic fever

Yes

Diagnosed heart condition or structural heart problem

Yes

Cardiac surgery, pacemaker, or implanted defibrillator

Yes

Wolff-Parkinson-White (WPW) syndrome or arrhythmia

Yes

Long QT syndrome or Brugada syndrome

Yes

Hypertrophic Cardiomyopathy (HCM) or enlarged heart

Yes

Marfan syndrome (tall stature, flexible joints, visual changes)

Yes

Sudden death or drowning in a family member under age 50

Yes

Family history of Long QT, HCM, or genetic heart condition

Yes

Family history of sudden cardiac death before age 50

Yes

GENERAL MEDICAL HISTORY

Concussion, head injury, or loss of consciousness

Yes

Seizures or epilepsy

Yes

Frequent or severe headaches

Yes

Dizziness, vertigo, or balance problems

Yes

Heat stroke, heat exhaustion, or heat illness

Yes

Sickle cell trait or sickle cell disease

Yes

Asthma, exercise-induced bronchospasm, or breathing problems

Yes

Diabetes (Type 1 or Type 2)

Yes

Anemia or blood disorders

Yes

Kidney disease or only one kidney

Yes

Missing or non-functioning paired organ (eye, testicle)

Yes

Eating disorder, disordered eating, or menstrual irregularity

Yes

Musculoskeletal injury requiring surgery or casting (past 2 years)

Yes

Allergy requiring an EpiPen or emergency medication

Yes

Current prescription or OTC medications

Yes

Prior disqualification from sports participation

Yes

Current Medications (include supplements/vitamins):

Explain any YES answers above:

SECTION 3 — PHYSICAL EXAMINATION

To be completed by Licensed Healthcare Provider

Date

Provider Name

Height

Weight

BMI

Pulse

BP Right Arm

BP Left Arm

Vision R: 20/

Vision L: 20/:

Body System

Status

Clinical Notes

Eyes / Vision / Pupils

Ears / Nose / Throat

Lymph Nodes

Dental / Oral Health

Thyroid / Neck

Chest / Lungs / Respiratory

Heart / Cardiovascular (Auscultation)

Abdomen / Organomegaly

Genitourinary (Males)

Skin / Dermatologic

Neurological

Musculoskeletal — Cervical Spine

Musculoskeletal — Shoulder / Upper Extremity

Musculoskeletal — Elbow / Wrist / Hand

Musculoskeletal — Back / Scoliosis Screen

Musculoskeletal — Hip / Knee / Ankle / Foot

Marfan Stigmata (arm span, pectus, lens)

Tanner Stage (Puberty Assessment)

SECTION 4 — ELECTROCARDIOGRAM (EKG / ECG)

GOOD TO GREAT WELLNESS CENTER STANDARD

EKG Parameter

Result / Value

Normal Range

Interpretation

Heart Rate

Result / Value

50–100 bpm (athletes: 40–100)

Interpretation

Normal

Abnormal

PR Interval

120–200 ms

Normal

Abnormal

QRS Duration

< 120 ms

Normal

Abnormal

QTc Interval (Bazett)

Male ≤ 440 ms / Female ≤ 460 ms

Normal

Abnormal

P-Wave Morphology

Upright in I, II; biphasic V1

Normal

Abnormal

ST Segment

Isoelectric (no elevation/depression)

Normal

Abnormal

T-Wave (V1–V4)

May be inverted in V1–V2 (athletes)

Normal

Abnormal

Axis (QRS)

-30° to +90°

Normal

Abnormal

LVH Pattern

Voltage criteria ± repolarization

Normal

Abnormal

RVH / RBBB Pattern

Incomplete RBBB common in athletes

Normal

Abnormal

Delta Wave (WPW)

Absent

Normal

Abnormal

Epsilon Wave (ARVC)

Absent

Normal

Abnormal

Arrhythmia / Ectopy

None at rest

Normal

Abnormal

Overall EKG Impression

None at rest

Normal

Abnormal

EKG Performed By:

Date of EKG

EKG Machine / Model

EKG Reviewed By (if different)

EKG Findings / Clinical Notes

SECTION 5 — PROVIDER CLEARANCE DETERMINATION

CLEARED — Unrestricted

Athlete is medically cleared for full participation in all sports and physical activities

CLEARED — With Conditions

Athlete is cleared with the restrictions listed below. Must be reviewed before each season.

NOT CLEARED — Disqualified

Athlete is medically disqualified from participation. Reason documented below.

NOT CLEARED — Pending Evaluation

Further workup required (cardiology, neurology, orthopedics, etc.) before clearance decision.

Conditions / Restrictions / Reason For Non-Clearance

Recommended Follow-Up / Referrals

Provider Signature

Printed Name

Credentials (MD / DO / APRN / PA)

Date

NPI Number

Clinic / Practice Name

Phone Number

Address

Street Address

State License #

SECTION 6 — PARENT / GUARDIAN CONSENT & SIGNATURE

I hereby certify that the medical history provided is accurate and complete to the best of my knowledge. I consent to the physical examination, 12-lead EKG, and any necessary follow-up evaluations described herein. I understand that this evaluation does not guarantee prevention of sports-related injury or illness and that the healthcare provider's determination is a medical recommendation, not a guarantee. I authorize Good to Great Family Wellness Center to release this information to the student's school and relevant sports officials as required.

Parent/Guardian Signature

Printed Name

Date

Relationship to Athlete

SECTION 7 — ATHLETE ACKNOWLEDGMENT

I have reviewed and verified the medical history provided above. I understand the importance of honest and accurate reporting. I agree to report any new symptoms, especially cardiac symptoms such as chest pain, palpitations, dizziness, or fainting, immediately to my coach, school nurse, or healthcare provider. I acknowledge receipt of the EKG results and clearance determination.

Parent/Guardian Signature

Printed Name

Date

Relationship to Athlete

Why Choose Good to Great?

SECTION 1 — STUDENT / ATHLETE INFORMATION

SECTION 2 — PERSONAL & FAMILY MEDICAL HISTORY

SECTION 3 — PHYSICAL EXAMINATION

SECTION 4 — ELECTROCARDIOGRAM (EKG / ECG)

SECTION 5 — PROVIDER CLEARANCE DETERMINATION

SECTION 6 — PARENT / GUARDIAN CONSENT & SIGNATURE

SECTION 7 — ATHLETE ACKNOWLEDGMENT

SECTION 3 — PHYSICAL EXAMINATION

CLEARED — Unrestricted

CLEARED — With Conditions

NOT CLEARED — Pending Evaluation

NOT CLEARED — Disqualified

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CARDIAC / CARDIOVASCULAR HISTORY
Chest pain, tightness, or pressure during exercise	Yes No
Fainting or near-fainting during or after exercise	Yes No
Unexplained shortness of breath during normal activity	Yes No
Heart palpitations, racing, skipping, or irregular heartbeat	Yes No
High blood pressure or high cholesterol	Yes No
A heart murmur (detected at birth or later)	Yes No
Kawasaki disease or rheumatic fever	Yes No
Diagnosed heart condition or structural heart problem	Yes No
Cardiac surgery, pacemaker, or implanted defibrillator	Yes No
Wolff-Parkinson-White (WPW) syndrome or arrhythmia	Yes No
Long QT syndrome or Brugada syndrome	Yes No
Hypertrophic Cardiomyopathy (HCM) or enlarged heart	Yes No
Marfan syndrome (tall stature, flexible joints, visual changes)	Yes No
Sudden death or drowning in a family member under age 50	Yes No
Family history of Long QT, HCM, or genetic heart condition	Yes No
Family history of sudden cardiac death before age 50	Yes No
GENERAL MEDICAL HISTORY
Concussion, head injury, or loss of consciousness	Yes No
Seizures or epilepsy	Yes No
Frequent or severe headaches	Yes No
Dizziness, vertigo, or balance problems	Yes No
Heat stroke, heat exhaustion, or heat illness	Yes No
Sickle cell trait or sickle cell disease	Yes No
Asthma, exercise-induced bronchospasm, or breathing problems	Yes No
Diabetes (Type 1 or Type 2)	Yes No
Anemia or blood disorders	Yes No
Kidney disease or only one kidney	Yes No
Missing or non-functioning paired organ (eye, testicle)	Yes No
Eating disorder, disordered eating, or menstrual irregularity	Yes No
Musculoskeletal injury requiring surgery or casting (past 2 years)	Yes No
Allergy requiring an EpiPen or emergency medication	Yes No
Current prescription or OTC medications	Yes No
Prior disqualification from sports participation	Yes No

EKG Parameter	Normal Range	Interpretation
Heart Rate	50–100 bpm (athletes: 40–100)	Normal Abnormal
PR Interval	120–200 ms	Normal Abnormal
QRS Duration	< 120 ms	Normal Abnormal
QTc Interval (Bazett)	Male ≤ 440 ms / Female ≤ 460 ms	Normal Abnormal
P-Wave Morphology	Upright in I, II; biphasic V1	Normal Abnormal
ST Segment	Isoelectric (no elevation/depression)	Normal Abnormal
T-Wave (V1-V4)	May be inverted in V1–V2 (athletes)	Normal Abnormal
Axis (QRS)	-30° to +90°	Normal Abnormal
LVH Pattern	Voltage criteria ± repolarization	Normal Borderline Abnormal
RVH / RBBB Pattern	Incomplete RBBB common in athletes	Normal Abnormal
Delta Wave (WPW)	Absent	Absent Present
Epsilon Wave (ARVC)	Absent	Absent Present
Arrhythmia / Ectopy	None at rest	None Present
Overall EKG Impression	Clinical Interpretation	Normal Borderline Abnormal