Sports Physical Form

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):

If other, specify:

List past and current medical conditions.

Have you ever had surgery? If yes, list all past surgical procedures.

Do you have any allergies? If yes, please list all your allergies (ie, 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

0 - Not at all 1- Several days 2 - Over half the days 3 -Nearly every day

Not being able to stop or control worrying

0 - Not at all 1- Several days 2 - Over half the days 3 -Nearly every day

Little interest or pleasure in doing things

0 - Not at all 1- Several days 2 - Over half the days 3 -Nearly every day

Feeling down, depressed, or hopeless

0 - Not at all 1- Several days 2 - Over half the days 3 -Nearly every day

(A sum of ≥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. Select 'I don't Know" if you don’t know the answer.)

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

HEART HEALTH QUESTIONS ABOUT YOU

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

10. Have you ever had a seizure?

Yes No I 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 I 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 I don't know

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

Yes No I 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 I don't know

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

Yes No I don't know

MEDICAL QUESTIONS

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I 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 I don't know

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

Yes No I 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 I don't know

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

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

25. Do you worry about your weight?

Yes No I don't know

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

Yes No I don't know

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

Yes No I don't know

28. Have you ever had an eating disorder?

Yes No I don't know

FEMALES ONLY

29. Have you ever had a menstrual period?

Yes No I don't know

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?

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 form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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, e-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 (Q4–Q13 of History Form).

EXAMINATION

Height:

Weight:

BP:

Pulse:

Vision: R 20/

L 20/

Corrected:

Yes No

MEDICAL

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

Normal

ABNORMAL FINDINGS

Eyes, ears, nose, and throat

Pupils equal

NORMAL

ABNORMAL FINDINGS

Hearing

NORMAL

ABNORMAL FINDINGS

Lymph nodes

NORMAL

ABNORMAL FINDINGS

Heart: Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)

NORMAL

ABNORMAL FINDINGS

Lungs

NORMAL

ABNORMAL FINDINGS

Abdomen

NORMAL

ABNORMAL FINDINGS

Skin: Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or tinea corporis

NORMAL

ABNORMAL FINDINGS

Neurological

NORMAL

ABNORMAL FINDINGS

MUSCULOSKELETAL

Neck

NORMAL

ABNORMAL FINDINGS

Back

NORMAL

ABNORMAL FINDINGS

Shoulder and arm

NORMAL

ABNORMAL FINDINGS

Elbow and forearm

NORMAL

ABNORMAL FINDINGS

Wrist, hand, and fingers

NORMAL

ABNORMAL FINDINGS

Hip and thigh

NORMAL

ABNORMAL FINDINGS

Knee

NORMAL

ABNORMAL FINDINGS

Leg and ankle

NORMAL

ABNORMAL FINDINGS

Foot and toes

NORMAL

ABNORMAL FINDINGS

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

NORMAL

ABNORMAL FINDINGS

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

Name of health care professional (print or type):

Date

Address:

Phone:

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

Signature of health care professional:

MEDICAL ELIGIBILITY FORM

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 pending further evaluation

Not medically eligible for any sports

Recommendations:

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings are 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 medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type):

Date

Address:

Phone:

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

Signature of health care professional:

SHARED EMERGENCY INFORMATION

Allergies:

Medications:

Other information:

Emergency contacts:

Your information will be encrypted.