FAMILY PRACTICE RESIDENCY PROGRAM EVALUATION
SPORTS MEDICINE
Please rate the physician named below in comparison to other family physicians with whom you have worked. Circle one rating
response per item. Circle the appropriate number between 1 and 5 where 1 is unable to pass and 5 is the highest rating. If you have
had insufficient contact to evaluate this physician on a particular characteristic, circle UE (Unable to Evaluate).
Name of Resident Physician _______________________________________ Rotation Dates ______________
Name of Evaluator _______________________________________________ Date ______________________
____________________________________________________________________________________________
RATING SCALE
1 = Unable to Pass*
2 = Learning
3 = Capable
4 = Proficient
5 = Mastery*
UE = Unable to Evaluate
* = Documentation Required
____________________________________________________________________________________________
1.
Obtains an accurate history with attention to those items that are of special interest to sports
1
2.
2
3
4
5
UE
Demonstrates knowledge of the rules and regulations governing sports participation and those conditions
which disqualify an athlete from participation
1
3.
2
3
4
5
UE
Understands preventive measures such as conditioning routines, equipment, taping and appropriateness of
returning to competition
1
4.
2
3
4
5
UE
Demonstrates knowledge and skills in the prevention, diagnosis, treatment and rehabilitation
of sports related injuries and the promotion of recreational activities and exercise
1
5.
5
UE
2
3
4
5
UE
2
3
4
5
UE
Understands the proper procedures for removal of the athlete from the playing field
1
8.
4
Demonstrates the proper performance of sports physicals
1
7.
3
Demonstrates knowledge of physical therapy techniques and modalities utilized for rehabilitation
1
6.
2
2
3
4
5
UE
Has a working knowledge of sports nutrition/supplementation
1
2
3
4
5
UE
9.
Demonstrates knowledge of banned substances
1
2
3
4
5
UE
Justification for 1 or 5_________________________________________________________________________
____________________________________________________________________________________________
Comments___________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________
Evaluators Signature
_______________________________________________________________
Program Directors Signature
_______________________________________________________________
Resident Signature