Preparticipation Physical Evaluation

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, please list all 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 (i.e. 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? (check box next to appropriate number)

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 > 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.

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

HEART HEALTH QUESTIONS ABOUT YOU

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

10. Have you ever had a seizure?

Yes No Don't Know

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 Don't Know

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 Don't Know

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

Yes No Don't Know

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 Don't Know

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

Yes No Don't Know

MEDICAL QUESTIONS

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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 Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

25. Do you worry about your weight?

Yes No Don't Know

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

Yes No Don't Know

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

Yes No Don't Know

28. Have you ever had an eating disorder?

Yes No Don't Know

FEMALES ONLY

29. Have you ever had a menstrua period?

Yes No Don't Know

30. How old are 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 12 months?

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.

Signature of athlete

Signature of parent or guardian

Date

ATHLETES WITH DISABILITY FORM: SUPPLEMENT TO THE ATHLETE HISTORY

Name

Date of Birth

1. Type of disability

2. Date of disability?

3. Classification (if available):

4. Cause of disability (birth, disease, injury, or other

5. List the sports you are playing

6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?

Yes No

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

Yes No

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

Yes No

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

Yes No

10. Do you have a visual impairment?

Yes No

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

Yes No

12. Do you have burning or discomfort when urinating?

Yes No

13. Have you had autonomic dysreflexia?

Yes No

14. Have you ever been diagnosed as having heat-related (hyperthermia) or cold-related (hypothermia) illness?

Yes No

15. Do you gave muscle spasticity?

Yes No

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

Yes No

Explain "Yes" answers here.

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

Atlantoaxial instability

Yes No

Radiographic (x-ray) evaluation for atlantoaxial instability

Yes No

Dislocated joints (more than one)

Yes No

Easy bleeding

Yes No

Enlarged spleen

Yes No

Hepatitis

Yes No

Osteopenia or Osteoporosis

Yes No

Difficulty controlling bowel

Yes No

Difficulty controlling bladder

Yes No

Numbness or tingling in arms or hands

Yes No

Numbness or tingling in legs or feet

Yes No

Weakness in arms or hands

Yes No

Weakness in legs or feet

Yes No

Recent change in coordination

Yes No

Recent change in ability to walk

Yes No

Spina bifida

Yes No

Latex allergy

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

Physical Examination Form

Name

Date of Birth

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

Height

Weight

Sex

Male Female

Pulse

Vision R

Vision L

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.

Name of healthcare professional

Date

Address

Phone

Signature of healthcare professional

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 for pending further evaluation

Not medically eligible for any sports

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 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).

Name of healthcare professional

Date

Address

Phone

Signature of healthcare professional

SHARED EMERGENCY INFORMATION

Allergies

Medications

Other Information

Emergency Contacts

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