Sports Form

To be completed by athlete or parent prior to examination.

Last Name

First

Middle

School Year

Address

City/State

Phone No.

Birthdate

Age

Class

Studen ID No.

Parent’s Name

Phone Number

Address

City/State

HISTORY FORM

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

List all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Add more

Do you have any allergies?

Yes No

If yes, please identify specific allergy below.

Medicines

Pollens

Food

Stinging Insects

GENERAL QUESTIONS

Explain “Yes” answers below.

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

Yes No

If Yes, please explain

2. Do you have any ongoing medical conditions?

Yes No

If Yes, please explain

If so, please identify below:

Asthma

Anemia

Diabetes

Infection

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

Yes No

If Yes, please explain

4. Have you ever had surgery?

Yes No

If Yes, please explain

HEART HEALTH QUESTIONS ABOUT YOU

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

Check all that apply:

High blood pressure

A heart murmur

High Cholesterol

A heart Infection

Kawasaki Disease

Other

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

11. Have you ever had an unexplained seizure?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

If Yes, please explain

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

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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 Option 2

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

20. Have you ever had a stress fracture?

Yes No

If Yes, please explain

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

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

MEDICAL QUESTIONS

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

Short text field

36. Do you have a history of seizure disorder?

Yes No

If Yes, please explain

37. Do you have headaches with exercise?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes Option 2

If Yes, please explain

41. Do you get frequent muscle cramps when exercising?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

44. Have you had any eye injuries?

Yes No

If Yes, please explain

45. Do you wear glasses or contact lenses?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

47. Do you worry about your weight?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

50. Have you ever had an eating disorder?

Yes No

If Yes, please explain

51. Have you or any family member or relative been diagnosed with cancer?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

FEMALES ONLY

53. Have you ever had a menstrual period?

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Yes No

If Yes, please explain

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

Physician’s Signature

Physician’s Name

Physician’s Assistant Signature*

PA’s Name

Advanced Nurse Practitioner’s Signature*

ANP’s Name

*effective January 2003, the IHSA Board of Directors approved a recommendation, consistent with the Illinois School Code, that allows Physician’s Assistants or Advanced Nurse Practitioners to sign off on physicals.

Your information will be encrypted.