Preparticipation Physical Evaluation

Please correct the errors described below.

History Form

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

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (check box next to appropriate number)

(A sum of > or equal to 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.

HEART HEALTH QUESTIONS ABOUT YOU

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

MEDICAL QUESTIONS

FEMALES ONLY

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.

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.

ATHLETES WITH DISABILITY FORM: SUPPLEMENT TO THE ATHLETE HISTORY

Explain "Yes" answers here.

Please indicate whether you have ever had any of the following conditions:

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.

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.

Physical Examination Form

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues

  • Do you feel stressed out or under a lot of pressure?
  • Do you ever feel sad, hopeless, depressed, or anxious?
  • Do you feel safe at your home or residence?
  • Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
  • During the past 30 days, did you use chewing tobacco, snuff, or dip?
  • Do you drink alcohol or use any other drugs?
  • Have you ever taken anabolic steroids or used any other performance supplement?
  • Have you ever taken any supplements to help you gain or lose weight or improve your performance?
  • Do you wear a seat belt, use a helmet, and use condoms?

2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

  • Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

  • Pupils equal
  • Hearing

Lymph nodes

Heart (a)

  • Murmurs (auscultation standing, supine, +/- Valsalva)
  • Location of point of maximal impulse (PMI)

Pulses

  • Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only) (b)

Skin

  • HSV, lesions suggestive of MRSA, tinea corporis

Neurologic (c)

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

Foot/toes

Functional

  • Duck-walk, single leg hop

*Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combination of those.

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.

Medical Eligibility Form

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate 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.

SHARED EMERGENCY INFORMATION

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