01
Athlete Information
Verified on intake
Athlete
Caleb T. Morrison
DOB: March 14, 2008 · Age 17
School
Northfield High School
Grade 12 · Student ID 2024-0891
Sport / Position
Varsity Football
Outside Linebacker · #44
Guardian
Melissa Morrison
Parent · (612) 555‑0398
Insurance
BlueShield PPO
Policy #BX‑44‑7712905
02
Injury & Recovery Summary
Chart #MR‑2024‑10442
Diagnosis
Complete, displaced midshaft clavicle fracture — right
Date of Injury
September 6, 2024
Treatment Course
Non‑operative · figure‑eight brace × 6 weeks · guided PT
03
Clearance Requirements
All items must be complete
✓
Radiographic confirmation of bony union
AP and cephalic‑tilt radiographs demonstrate bridging callus across the fracture line with restoration of cortical continuity. No residual displacement > 5 mm.
X‑Ray Date
November 18, 2024
Healed
✓
Physical therapy program completed
Twelve supervised sessions with Northfield Orthopedic PT. Full, pain‑free shoulder range of motion restored. Rotator cuff and scapular strength measured at 95% of contralateral limb via handheld dynamometry.
Discharge
November 22, 2024
Graduated
✓
Functional & sport‑specific testing
Successfully completed progressive tackle‑simulation protocol, medicine ball chest pass (symmetric), plank‑to‑push load tolerance, and contact helmet/shoulder pad trial without reproduction of pain or apprehension.
Test Date
November 25, 2024
Passed
✓
Physician examination & attestation
In‑person follow‑up with supervising orthopedic surgeon. Neurovascular exam intact. No tenderness on palpation. Cross‑body adduction and O'Brien's test negative.
Exam Date
November 26, 2024
Cleared
04
Activity Parameters
Effective December 2, 2024
Authorized Activities
- Full contact practice and competition
- Weight training without restriction
- Tackling, blocking, and collision drills
- Conditioning and agility at full intensity
Precautions for 30 Days
- Properly fitted shoulder pads required at all contact
- Report any recurrent pain at fracture site immediately
- No return to play if new shoulder trauma occurs
- Follow‑up recheck on January 15, 2025
05
Physician Attestation & Signatures
Required for release to athletic staff
I have personally examined the above‑named athlete, reviewed imaging and rehabilitation records, and find no medical contraindication to full, unrestricted participation in varsity football. This clearance is issued in accordance with the state high school athletic association return‑to‑play protocol.
Harold J. Whitaker, MD
Supervising Physician
Harold J. Whitaker, MD — Orthopedic Surgery
Board Certified · State License #MN‑44881 · NPI 1487‑992‑305
Melissa Morrison
Parent / Legal Guardian
Acknowledgment of clearance terms
Confirms receipt of post‑injury instructions and 30‑day precaution period.