Preparation Physical Evaluation

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam

Name

Date of Birth

Age

Grade

School

Sport(s)

Medicines and Allergies: Please list all the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?

Yes No

If yes, please specify

Medicines

Pollens

Food

Stinging Insects

Explain "Yes" answers below.

GENERAL QUESTIONS

1. Has a doctor ever denied or restricted your participation in sports for any reason?

Yes No

2. Do you have any ongoing medical conditions? If so, please identify below

Yes No

Asthma

Anemia

Diabetes

Infections

Other

If other, please specify

3. Have you ever spent the night in the hospital?

Yes No

4. Have you ever had surgery?

Yes No

HEART HEALTH QUESTIONS ABOUT YOU

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

Yes No

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

Yes No

7. Does your heart ever race or skip beats (irregular beats) during exercise?

Yes No

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply below

Yes No

High blood pressure

High cholesterol

Kawasaki disease

A heart murmur

A heart infection

Other

If other, please specify

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

Yes No

10. Do you get lightheaded or feel more short of breath than expected during exercise?

Yes No

11. Have you ever had an unexplained seizure?

Yes No

12. Do you get more tired or short of breath more quickly than you friends during exercise?

Yes No

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?

Yes No

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

Yes No

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

Yes No

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

Yes No

BONE AND JOINT QUESTIONS

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

Yes No

18. Have you ever had any broken or fractured bones or dislocated joints?

Yes No

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

Yes No

20. Have you ever had a stress fracture?

Yes No

21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

Yes No

22. Do you regularly use a brace, orthotics, or other assistive device?

Yes No

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

Yes No

24. Do any of your joints become painful, swollen, feel warm, or look red?

Yes No

25. Do you have any history of juvenile arthritis or connective tissue disease?

Yes No

MEDICAL QUESTIONS

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

Yes No

27. Have you ever used an inhaler or taken asthma medicine?

Yes No

28. Is there anyone in your family who has asthma?

Yes No

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

Yes No

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

Yes No

31. Have you had infections mononucleosis (mono) within the last month?

Yes No

32. Do you have any rashes, pressure sores, or other skin problems?

Yes No

33. Have you had a herpes or MRSA skin infection?

Yes No

34. Have you ever had a head injury or concussion?

Yes No

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

Yes No

36. Do you have a history of seizure disorder?

Yes No

37. Do you have headaches with exercise?

Yes No

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

Yes No

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

Yes No

39. Have you ever been unable to move your arms or legs after being hit or falling?

Yes No

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

Yes No

41. Do you get frequent muscle cramps when exercising?

Yes No

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

Yes No

43. Have you had any problems with your eyes or vision?

Yes No

44. Have you had any eye injuries?

Yes No

45. Do you wear glasses or contact lenses?

Yes No

46. Do you wear protective eyewear, such as goggles or a face shield?

Yes No

47. Do you worry about your weight?

Yes No

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

Yes No

49. Are you on a special diet or do you avoid certain types of foods?

Yes No

50. Have you ever had an eating disorder?

Yes No

51. Do you have any concerns that you would like to discuss with a doctor?

Yes No

FEMALES ONLY

52. Have you ever had a menstrual period?

Yes No

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

Yes No

54. How many periods have you had in the last 12 months?

Yes No

Explain "yes" answers here:

Add another "yes" answer

I hereby state that, to the best of my knowledge, my answers to the above questions 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 / Guardian

Date

THE ALTHLETE WITH SPECIAL NEEDS:

SUPPLEMENTAL HISTORY

Type of disability

Date of disability

Classification (If available)

Cause of disability (Birth, disease, accident/trauma, other)

List the sports you are interested in playing

Do you regularly use a brace, assistive device, or prosthetic?

Yes No

If yes, please explain

Do you regularly use any special brace or assistive device for sports?

Yes No

If yes, please explain

Do you have any rashes, pressure sores, or any other skin problems?

Yes No

If yes, please explain

Do you have a hearing loss? Do you use a hearing aid?

Yes No

If yes, please explain

Do you have a visual impairment?

Yes No

If yes, please explain

Do you use any special devices for bowel or bladder function?

Yes No

If yes, please explain

Do you haev burning or discomfort when urinating?

Yes No

If yes, please explain

Have you had autonomic dysreflexia?

Yes No

If yes, please explain

Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

Yes No

If yes, please explain

Do you have muscle spasticity?

Yes No

If yes, please explain

Do you have frequent seizures that cannot be controlled by medication?

Yes No

If yes, please explain

If other, specify

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

Signature of athlete

Signature of parent / guardian

Date

PHYSICAL EXAMINATION FORM

Consider additional questions on more sensitive issues:

Do you feel stressed out or under a lot of pressure?

Yes No

Do you ever feel sad, hopeless, depressed, or anxious?

Yes No

Do you feel safe at your home or residence?

Yes No

Have you ever tried cigarettes, chewing tobacco, snuff, or dip?

Yes No

During the past 30 days, did you use chewing tobacco, snuff, or dip?

Yes No

Do you drink alcohol or use any other drugs?

Yes No

Have you ever taken anabolic steroids or used any other performance supplement?

Yes No

Have you ever taken any supplements to help you gain or lose weight or improve your performance?

Yes No

Do you wear a seatbelt, use a helmet, and use condoms?

Yes No

Consider reviewing questions on cardiovascular symptoms (questions 5-14)

EXAMINATION

Height

Weight

Pulse

Vision R

MEDICAL

Add new row

MUSCULOSKELETAL

Add new row

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

Not Cleared

Pending Further Evaluation

For any Sports

For Certain Sports

Reason

Recommendations

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participates in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

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.

Name / Signature of Physician

Date

Address

Phone

CLEARANCE FORM

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

Not Cleared

Pending Further Evaluation

For Any Sports

For Certain Sports

Reason

Recommendations

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.

Name / Signature of Physician

Date

Address

Phone

EMERGENCY INFORMATION

Allergies

Other Information

Your information will be encrypted.

Preparation Physical Evaluation

Explain "Yes" answers below.

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

THE ALTHLETE WITH SPECIAL NEEDS:

PHYSICAL EXAMINATION FORM

EXAMINATION

CLEARANCE FORM

EMERGENCY INFORMATION

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