Preparticipation Physical Evaluation Form

MEDICAL ELIGIBILITY FORM

Name

Date of Birth

Medically eligible for all sports without restriction

Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

Medically eligible for certain sports

Not medically eligible pending further evaluation

Not medically eligible for any sports

Recommendations

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings are 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 medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or 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 of health care professional

Date

Address

Phone

Signature of health care professional

SHARED EMERGENCY INFORMATION

Allergies

Medications

Other information

Emergency contacts

Supplemental COVID‐19 questions

1. Have you had any of the following symptoms in the past 14 days?

a) Fever or chills

Yes No

b) Cough

Yes No

c) Shortness of breath or difficulty breathing

Yes No

d) Fatigue

Yes No

e) Muscle or body aches

Yes No

f) Headache

Yes No

g) New loss of taste or smell

Yes No

h) Sore throat

Yes No

i) Congestion or runny nose

Yes No

j) Nausea or vomiting

Yes No

k) Diarrhea

Yes No

l) Date symptoms started

m) Date symptoms resolved

2. Have you ever had a positive test for COVID‐19?

Yes No

If yes:

i. Date of test

ii. Were you tested because you had symptoms?

Yes No

If yes:

a) Date symptoms started

b) Date symptoms resolved

c) Were you hospitalized?

Yes No

d) Did you have fever > 100.4 F.?

Yes No

If yes, how many days did your fever last?

e) Did you have muscle aches, chills, or lethargy?

Yes No

If yes, how many days did these symptoms last?

f) Have you had the vaccine?

Yes No

iii. Were you tested because you were exposed to someone with COVID‐19, but you did not have any symptoms?

Yes No

3. Has anyone living in your household had any of the following symptoms or tested positive for COVID‐19 in the past 14 days?

Yes No

4. Have you been within 6 feet for more than 15 minutes of someone with COVID‐19 in the past 14 days?

Yes No

If yes: date(s) of exposure

5. Are you currently waiting on results from a recent COVID test?

Yes No

Sources:

Interim Guidance on the Preparticipation Physical Examinatio... : Clinical Journal of Sport Medicine (lww.com)
Supplemental COVID‐19 Questions (lww.com)
COVID‐19 Interim Guidance: Return to Sports and Physical Activity (aap.org)

HISTORY FORM

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)

Sex assigned at birth (F, M, or intersex)

How do you identify your gender? (F, M, or other)

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? (Select response.)

Feeling nervous, anxious, or on edge

Not at all [0] Several days [1] Over half the days [2] Nearly every day [3]

Not being able to stop or control worrying

Not at all [0] Several days [1] Over half the days [2] Nearly every day [3]

Little interest or pleasure in doing things

Not at all [0] Several days [1] Over half the days [2] Nearly every day [3]

Feeling down, depressed, or hopeless

Not at all [0] Several days [1] Over half the days [2] Nearly every day [3]

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

GENERAL QUESTIONS

(Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.)

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

Yes No

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

Yes No

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

Yes No

HEART HEALTH QUESTIONS ABOUT YOU

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

10. Have you ever had a seizure?

Yes No

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

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

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

Yes No

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

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

Yes No

MEDICAL QUESTIONS

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

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

Yes No

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

Yes No

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

Yes No

25. Do you worry about your weight?

Yes No

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

Yes No

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

Yes No

28. Have you ever had an eating disorder?

Yes No

FEMALES ONLY

29. Have you ever had a menstrual period?

Yes No

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

Yes No

31. When was your most recent menstrual period?

Yes No

32. How many periods have you had in the past 12 months?

Yes No

Explain “Yes” answers here

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

Signature of athlete

Signature of parent or guardian

Date

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