Preparticipation Physical Evaluation

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

Name

Date of Birth

Date of examination

Sport(s)

List past and current medical conditions.

Have you ever had surgery? If yes, list all past surgical procedures.

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).

Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

General Questions

1. Do you have any concerns that you would like to discuss with your provider?

Yes No

If yes, Please explain

2. Has a provider ever denied or restricted your participation in sports for any reason?

Yes No

If yes, Please explain

3. Do you have any ongoing medical issues or recent illness?

Yes No

If yes, Please explain

Heart Health Question About you

4. Have you ever passed out or nearly passed out during or after exercise?

Yes No

If yes, Please explain

5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Yes No

If yes, Please explain

6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?

Yes No

If yes, Please explain

7. Has a doctor ever told you that you have any heart problems?

Yes No

If yes, Please explain

8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography

Yes No

If yes, Please explain

Heart Health Questions About You

9. Do you get light-headed or feel shorter of breath than your friends during exercise?

Yes No

If yes, Please explain

10. Have you ever had a seizure?

Yes No

If yes, Please explain

Heart Health Questions About Your Family

11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?)

Yes No

If yes, Please explain

12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?

Yes No

If yes, Please explain

13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

Yes No

If yes, Please explain

Bone And Joint Questions

14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?

Yes No

If yes, Please explain

15. Do you have a bone, muscle, ligament, or joint injury that bothers you?

Yes No

If yes, Please explain

Medical Questions

16. Do you cough, wheeze, or have difficulty breathing during or after exercise?

Yes No

If yes, Please explain

17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

Yes No

If yes, Please explain

18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

Yes No

If yes, Please explain

19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

Yes No

If yes, Please explain

20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

Yes No

If yes, Please explain

21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?

Yes No

If yes, Please explain

22. Have you ever become ill while exercising in the heat?

Yes No

If yes, Please explain

23. Do you or does someone in your family have sickle cell trait or disease?

Yes No

If yes, Please explain

24. Have you ever had or do you have any problems with your eyes or vision?

Yes No

If yes, Please explain

Medical Questions

25. Do you worry about your weight?

Yes No

If yes, Please explain

26. Are you trying to or has anyone recommended that you gain or lose weight?

Yes No

If yes, Please explain

27. Are you on a special diet or do you avoid certain types of foods or food groups?

Yes No

If yes, Please explain

28. Have you ever had an eating disorder?

Yes No

If yes, Please explain

Females Only

29. Have you ever had a menstrual period?

Yes No

If yes, Please explain

30. How old were you when you had your first menstrual period?

31. When was your most recent menstrual period?

32. How many periods have you had in the past twelve months?

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of athlete

Signature of parent or guardian

Date

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

Your information will be encrypted.