CMC English UIL Physical Form

PREPARTICIPATION PHYSICAL EVALUATION - MEDICAL HISTORY

This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.

Student's Name:

Sex:

Male Female

Age:

Date of Birth:

Address:

Phone:

Grade:

School:

Personal Physician:

Phone:

In case of emergency, contact:

Name:

Relationship:

Phone (Home):

Phone (Work):

1.) Have you had a medical illness or injury since your last check up or sports physical?

Yes No

2.) Have you been hospitalized overnight in the past year?

Yes No

2.a) Have you ever had surgery?

Yes No

3.) Have you ever had prior testing for the heart ordered by a physician?

Yes No

3.a) Have you ever passed out during or after exercise?

Yes No

3.b) Have you ever had chest pain during or after exercise?

Yes No

3.c) Do you get tired more quickly than your friends do during exercise?

Yes No

3.d) Have you ever had racing of your heart or skipped heartbeats?

Yes No

3.e) Have you had high blood pressure or high cholesterol?

Yes No

3.f) Have you ever been told you have a heart murmur?

Yes No

3.g) Has any family member or relative died of heart problems or of sudden unexpected death before age 50?

Yes No

3.h) Has any family member been diagnosed with enlarged heart, (dilated cardiomyopathy), hypertrophic cardiomyopathy, long QT syndrome or other ion channelpathy (Brugada syndrome, etc), Marfan's syndrome, or abnormal heart rhythm?

Yes No

3.i) Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month? Has a physician ever denied or restricted your participation in sports for any beart problems?

Yes No

4.) Have you ever had a head injury or concussion?

Yes No

4.a) Have you ever been knocked out, become unconscious, or lost your memory?

Yes No

4.b) If yes, how many times?

4.c) When was your last concussion?

4.d) How severe was each one? (Explain below)

4.e) Have you ever had a seizure?

Yes No

4.f) Do you have frequent or severe headaches?

Yes No

4.g) Have you ever had numbness or tingling in your arms, hands, legs or feet?

Yes No

4.h) Have you ever had a stinger, burner, or pinched nerve?

Yes No

5.) Are you missing any paired organs?

Yes No

6.) Are you under a doctor's care?

Yes No

7.) Are you currently taking any prescription or non-prescription (over-the-counter) medication or pills or using an inhaler?

Yes No

8.) Do you have any allergies (for example, to pollen, medicine, food, or stinging insects)?

Yes No

9.) Have you ever been dizzy during or after exercise?

Yes No

10.) Do you have any current skin problems (for example, itching, rashes, acne, warts, fungus, or blisters)?

Yes No

11.) Have you ever become ill from exercising in the heat?

Yes No

12.) Have you had any problems with your eyes or vision?

Yes No

13.) Have you ever gotten unexpectedly short of breath with exercise?

Yes No

13.a) Do you have asthma?

Yes No

13.b) Do you have seasonal allergies that require medical treatment?

Yes No

14.) Do you use any special protective or corrective equipment or devices that aren't usually used for your sport or position (for example, knee brace, special neck roll, foot orthotics, retainer on your teeth, hearing aid)?

Yes No

15.) Have you ever had a sprain, strain, or swelling after injury?

Yes No

15.a) Have you broken or fractured any bones or dislocated any joints?

Yes No

15.b) Have you had any other problems with pain or swelling in muscles, tendons, bones, or joints?

Yes No

and explain below:

16.) Do you want to weigh more or less than you do now?

Yes No

17.) Do you feel stressed out?

Yes No

18.) Have you ever been diagnosed with or treated for sickle cell trait or sickle cell disease?

Yes No

Females Only

19.) When was your first menstrual period?

19.a) When was your most recent menstrual, period?

19.b) How much time do you usually have from the start of one period to the start of another?

19.c) How many periods have you had in the last year?

19.d) What was the longest time between periods in the last year?

Males Only

20.) Do you have two testicles?

21.) Do you have any testicular swelling or masses?

An individual answering in the affirmative to any question relating to a possiule cardiovascular health issue (question three above), as identified on the form, should be restricted from further participation until the individual is examined and cleared by a physician, physician assistant, chiropractor, or nurse practitioner.

It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any responsibility in case an accident occurs.

If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indentify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.

If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury.

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL.

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

Student Name:

Parent/Guardian Name:

Date:

Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include A physical examination. Written clearance from a physican, physician assistant. cbicopractor, or nurse practitioner is required before any participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER SCHOOL.

For School Use Only:

This Medical History Form was received by:

Printed Name:

Date:

PREPARTICIPATION PHYSICAL EVALUATION - PHYSICAL EXAMINATION

Student's Name:

Sex:

Male Female

Age:

Date of Birth:

Height:

Weight:

% Body fat (optional):

Pulse:

BP:

brachial blood pressure while sitting

Vision:

R 20/

L 20/

Corrected:

Yes No

Pupils:

Equal Unequal

As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation and again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to specific questions on the student's MEDICAL HISTORY FORM.
* Local district policy may require an anllual physical exam.

MEDICAL

Appearance

NORMAL

ABNORMAL FINDINGS

INITIALS*

Eyes/Ears/Nose/Throat

NORMAL

ABNORMAL FINDINGS

INITIALS*

Lymph Nodes

NORMAL

ABNORMAL FINDINGS

INITIALS*

Heart-Auscultation of the heart in the supine position

NORMAL

ABNORMAL FINDINGS

INITIALS*

Heart-Auscultation of the heart in the standing position

NORMAL

ABNORMAL FINDINGS

INITIALS*

Heart-Lower extremity pulses

NORMAL

ABNORMAL FINDINGS

INITIALS*

Pulses

NORMAL

ABNORMAL FINDINGS

INITIALS*

Lungs

NORMAL

ABNORMAL FINDINGS

INITIALS*

Abdomen

NORMAL

ABNORMAL FINDINGS

INITIALS*

Genitalia (males only)

NORMAL

ABNORMAL FINDINGS

INITIALS*

Skin

NORMAL

ABNORMAL FINDINGS

INITIALS*

Marfan's stigmata (arachnodactyly, pectus excavatum, joint hypermobility, scoliosis)

NORMAL

ABNORMAL FINDINGS

INITIALS*

MUSCULOSKELETAL

Neck

NORMAL

ABNORMAL FINDINGS

INITIALS*

Back

NORMAL

ABNORMAL FINDINGS

INITIALS*

Shoulder/Arm

NORMAL

ABNORMAL FINDINGS

INITIALS*

Elbow/Forearm

NORMAL

ABNORMAL FINDINGS

INITIALS*

Wrist/Hand

NORMAL

ABNORMAL FINDINGS

INITIALS*

Hip/Thigh

NORMAL

ABNORMAL FINDINGS

INITIALS*

Knee

NORMAL

ABNORMAL FINDINGS

INITIALS*

Leg/Ankle

NORMAL

ABNORMAL FINDINGS

INITIALS*

Foot

NORMAL

ABNORMAL FINDINGS

INITIALS*

*station-based exatnination only

CLEARANCE

Cleared

Yes No

Cleared after completing evaluation/rehabilitation

Yes No

If "Cleared after completing evaluation/rehabilitation" is answered as yes, please specify:

Not cleared

Yes No

If "Not cleared" is answered as yes, please specify:

If "Not cleared" is answered as yes, please give reasons:

Recommendations:

The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board of Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners, or a Doctor of Chiropractic. Examination forms signed by any, other health care practitioner, will not be accepted.

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

Name (print/type)

Date of Examination:

Address:

Phone Number:

Must be completed before a student participates in any practice, before, during or after school. (both in-season and out-of-season) or games/matches.

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