PRE-PARTICIPATION PHYSICAL EVALUATION

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-enhancing 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 4-13 of History Form)

EXAMINATION

Height

Weight

Pulse

Vision: Right

Vision: Left

Corrected

Yes No

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse (MVP) and aortic insufficiency)

Eyes, ears, nose and throat

Pupils equal
Hearing

Lymph Nodes

Heart*

Murmurs (auscultation standing, auscultation supine and +/- Valsalva maneuver)

Lungs

Abdomen

Skin

Herpes simplex virus (HSV), lesions suggestive of methicillinresistant Staphylococcus aureus (MRSA) or tinea corporis

Neurological

MUSCULOSKELETAL

NORMAL

ABNORMAL FINDINGS

Neck

Back

Shoulder and arm

Elbow and forearm

Wrist, hand and fingers

Hip and thigh

Knee

Leg and ankle

Foot and toes

Functional

Double-leg squat test, single-leg squat test and box drop or step drop test

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

Cleared for all sports without restriction for two (2) years

Cleared for all sports without restriction for two (2) years with recommendation for further evaluation or treatment for:

Cleared for all sports without restriction for less than two (2) years. Specify reasons and duration of approval below:

Not Cleared

Pending further evaluation

For any sports

For certain sports (please list)

Reason for pending further evaulation

List of Certain Sports

Recommendations/Comments

I have examined the above-named student and completed the pre-participation 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.

Name of healthcare professional

Date of Issue

Address

Phone

Signature of healthcare professional (MD/DO/ARNP/PA/Chiropractor)

MEDICAL HISTORY

Note: Complete and sign this form (with your parents if younger than 18) before your appointment. The physician should keep a copy of this form in the chart for their records.

Note: An injury or medical condition results in a separate medical release.

Name

Date of Birth

Date of Examination

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 of 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 (circle 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.

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

GENERAL QUESTIONS

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 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 ordered 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 (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?

31. When was your most recent menstrual period?

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

IF “YES,” EXPLAIN ANSWERS HERE

Place the number for any question you would circle 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(s) or Guardian

Date

Your information will be encrypted.