PE EXCUSE OR MODIFIED PE LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]
To: [PE teacher, school nurse, or principal, and the school's name]

Student: [Student's full name]
Date of birth: [Date]
Grade or class: [Grade, if known]

I assessed [student name] on [date of the visit], [in person, by video, or by phone]. [Parent or guardian name, or the student if an adult] asked for this letter and agreed to what it shares.

PARTICIPATION IN PE
[Modified PE, or excused from all PE activities] from [first date] to [last date].
I will review this on: [Date of the next visit, or when I will send the school an update]

ACTIVITIES TO AVOID
[Each one named, with the side if it matters, e.g. no contact games, no running or jumping, no weight-bearing on the left leg, no swimming while the cast is on]

ACTIVITIES THAT ARE FINE
[What the student can still do, e.g. walking, a stationary bike, upper-body or leg work, stretching, scorekeeping or refereeing]

GETTING BACK TO FULL PE
[Full PE from a date with no limits; or a graded return: each step, at least how long it lasts, and which steps wait for my written clearance]

WARNING SIGNS
Stop the activity and contact [parent or guardian] if: [The signs that matter for this student, e.g. returning headache, numb or blue fingers, new swelling]
Call emergency services if: [Red-flag signs, or not applicable]

REASON
[Not included; or, with consent, the injury or condition in plain words]

[Your name, credentials]
[License or registration number]
[Signature]

Questions about these limits: [Practice phone or email]