Pre-participation Examination

To be completed by athlete or parent prior to examination.

Last:

First:

Middle:

School Year:

Address

City

State

Phone Number:

Birthdate

Age

Class

Student ID No.

Parent's Name

Phone No.

Address

City

State

HISTORY FORM

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

Do you have any allergies?

Yes No

If yes, please identify specific allergy below.

Medicines

Pollens

Food

Stinging Insects

Explain "Yes" answers below Circle questions you don't know the answers to.

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?

Yes No

If so, please identify below:

Asthma

Anemia

Diabetes

Infections

Other:

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?

Yes No

If so, 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

10. Do you get light headed 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 your 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 OT 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 infectious 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 hi story 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

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 ea ting disorder?

Yes No

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

Yes No

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

Yes No

FEMALES ONLY

53. Have you ever had a menstrual period?

Yes No

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

Yes No

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

Yes No

Explain "yes" answers here

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:

PHYSICAL EXAMINATION FORM

EXAMINATION

Height

Weight

Sex

Male Female

Pulse

Vision R 20/

Vision L20/

Corrected

Yes No

MEDICAL

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

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

Pulses

Simultaneous femoral and radial pulses

Lungs
Abdomen
Genitourinary (males only)
Skin

HSV, lesions suggestive of MRSA, tinea corporis

Neurologic

MUSCULOSKELETAL

Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/Ankle
Foot/toes
Functional

Duck-walk, single leg hop

• Consider KG. echocardiogram. and referral to cardiology for abnormal cardiac history or exam .
• Consider GU exam if In private setting. Having third party present is recommended.
• Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion

On the basis of the examination on this day, I approve this child's participation in interscholastic sports for 395 days from this date.

Yes No Limited

Examination Date

Additional Comments:

Physician's Name/Signature

Physician's Assistant Name/Signature

Advanced Nurse Practitioner's Name/Signature

*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.

IHSA Steroid Testing Policy Consent to Random Testing

(This section for high school students only)
2012-2013 school term

As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student's high school as specified in the IHSA Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student 10 penal ties as determined by IHSA.

A complete list of the current IHSA Banned Substance Classes can be accessed at
http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes. pdf

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 student-athlete

Date

Name/Signature of parent-guardian

Date

IHSA SKIN CONDITION EVALUATION AND AUTHORIZATION TO COMPETE IN HIGH SCHOOL WRESTLING

National Federation Wrestling Rules state:

"ART 3 .. If a participant is suspected by the referee or coach of having a communicable skin disease or any other condition that makes participation appear inadvisable, the coach shall provide current written documentation as defined by the NFHS or the state associations, from an appropriate heath-care professional stating that the suspected disease or condition is not communicable and that the athlete's participation would not be harmful to any opponent. This document shall be furnished at the weigh-in for the dual meet or tournament. The only exception would be if a designated, on-site meet appropriate health-care professional is present and is able to examine the wrestler either immediately prior to or immediately after the weigh-in. Covering a communicable condition shall not be considered acceptable and does not make the wrestler eligible to participate."

"ART 4 .. If a designated an-site meet appropriate health-care professional is present, he/she may overrule the diagnosis of the appropriate healthcare professional signing the medical release form for a wrestler to participate or not participate with a particular skin condition."

Once a lesion is considered non-contagious, it may be covered to allow participation .

NOTE: On the day of a meet, the following may review a wrestler's condition: M.D., D.O., P.A., APRN, and ATC's.
In the absence of one of the previously-mentioned people, the referee has the final decision concerning the wrestler's participation.

This form is for the following wrestler:

(Name of wrestler)

1. Indicate the specific location of the suspected skin condition on the figures below.

2. Describe the approximate size and color of the condition.

( example: it is about the size of a nickel, red in color, etc. )

3. Select One:

This wrestler's skin condition is contagious. He/she MAY NOT PARTICIPATE. This wrestler's skin condition is not contagious. He/she MAY NOT PARTICIPATE.

If this is a birthmark , non-communicable skin condition, i.e. psoriasis or eczema

check if YES (Valid for the year)

Note to schools: Medical authorization to compete expires 14 calendar days from the date of the examination.

Health Professional assumes all responsibility for this decision.

Print Healthcare Professional's name:

I am a/an

M.D. D.O. Physician's Assistant Advanced Practice Nurse/Nurse Practitioner

Healthcare Professional's signature:

Healthcare Professional's phone number:

Examination date:

State of Illinois Certificate of Child Health Examination

Student's Name

Last Name:

First Name

Middle Name

Birth Date

Sex

Race/Ethnicity

School/Grade Level/lD#

Address:

Street

City

Zip Code

Parent/Guardian

Telephone # Home:

Telephone # Work:

HEALTH HISTORY

TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

ALLERGIES (Food, drug, insect, other)

Yes No

If Yes, Please add to list

Diagnosis of asthma?

Yes No

Child wakes during night coughing?

Yes No

Birth Defects?

Yes No

Developmental delay?

Yes No

Blood disorders? Hemophilia, Sickle Cell?

Yes No

Other? Explain.

Diabetes?

Yes No

Head injury/Concussion/Passed out?

Yes No

Seizures? What are they like?

Yes No

Heart problem/Shortness of Breath?

Yes No

Heart murmur/High blood pressure?

Yes No

Dizziness or chest pain with exercise?

Yes No

Eye vision problems?

Yes No

Other concerns?

(crossed eye, drooping lids, squinting, difficulty reading)

Glasses

Contacts

Last exam by eye doctor

Ear/Hearing problems?

Yes No

Bone/Joint problem/ injury/scoliosis?

Yes No

MEDICATION (Prescribe or taken on a regular basis.)

Yes No

If Yes, Please add to list

Loss of function of one of paired organs? (eye/ear/kidney/testicle)

Yes No

Hospitalizations?

If Yes, When?

What for?

Surgery?

Yes No

If Yes, Please add to list

If Yes, When?

What for?

Serious injury or illness?

Yes No

TB skin test positive (past/present)?

Yes No

If yes, refer to local health department.

TB disease (past or present)?

Yes No

If yes, refer to local health department.

Tobacco use (type, frequency)?

Yes No

Alcohol/Drug use?

Yes No

Family history of sudden death before age 50?

Yes No

If Yes, what is the Cause?

Dental

Braces

Bridge

Plate

Other

Information may be shared with appropriate personnel for health and educational purposes.

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.

Parent/Guardian Signature

Date

Your information will be encrypted.