Preparticipation Physical Evaluation

HISTORY FORM

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam

Name

Sex

Male Female

Age

Grade

School

Sport(s)

Medicines and Allergies: Please list all of the prescription and over-the-counter 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. Check DK for 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 DK

2. Do you have any ongoing medical conditions?

Yes No DK

If yes, please identify below:

Asthma

Anemia

Diabetes

Infections

Other:

3. Have you ever spent the night in the hospital?

Yes No DK

4. Have you ever had surgery?

Yes No DK

HEART HEALTH QUESTIONS ABOUT YOU

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?

Yes No DK

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

Yes No DK

7. Does your heart ever race or skip beats (irregular beats) during exercise?

Yes No DK

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

Yes No DK

If yes, check all that apply:

High blood pressure

High cholesterol

Kawasaki disease

A heart murmur

A heart infection

Other:

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

Yes No DK

10. Do you get lightheaded or feel more short of breath than expected during exercise?

Yes No DK

11. Have you ever had an unexplained seizure?

Yes No DK

12. Do you get more tired or short of breath more quickly than your friends during exercise?

Yes No DK

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 DK

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

Yes No DK

15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?

Yes No DK

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

Yes No DK

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 DK

18. Have you ever had any broken or fractured bones or dislocated joints?

Yes No DK

19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?

Yes No DK

20. Have you ever had a stress fracture?

Yes No DK

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 DK

22. Do you regularly use a brace, orthotics, or other assistive device?

Yes No DK

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

Yes No DK

24. Do any of your joints become painful, swollen, feel warm, or look red?

Yes No DK

25. Do you have any history of juvenile arthritis or connective tissue disease?

Yes No DK

MEDICAL QUESTIONS

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

Yes No DK

27. Have you ever used an inhaler or taken asthma medicine?

Yes No DK

28. Is there anyone in your family who has asthma?

Yes No DK

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

Yes No DK

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

Yes No DK

31. Have you had infectious mononucleosis (mono) within the last month?

Yes No DK

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

Yes No DK

33. Have you had a herpes or MRSA skin infection?

Yes No DK

34. Have you ever had a head injury or concussion?

Yes No DK

35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?

Yes No DK

36. Do you have a history of seizure disorder?

Yes No DK

37. Do you have headaches with exercise?

Yes No DK

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?

Yes No DK

39. Have you ever been unable to move your arms or legs after being hit or falling?

Yes No DK

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

Yes No DK

41. Do you get frequent muscle cramps when exercising?

Yes No DK

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

Yes No DK

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

Yes No DK

44. Have you had any eye injuries?

Yes No DK

45. Do you wear glasses or contact lenses?

Yes No DK

46. Do you wear protective eyewear, such as goggles or a face shield?

Yes No DK

47. Do you worry about your weight?

Yes No DK

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

Yes No DK

49. Are you on a special diet or do you avoid certain types of foods?

Yes No DK

50. Have you ever had an eating disorder?

Yes No DK

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

Yes No DK

FEMALES ONLY

52. Have you ever had a menstrual period?

Yes No DK

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

Yes No DK

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

Yes No DK

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

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

Signature of athlete

Signature of parent/guardian

Date

THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM

Date of Exam

Name:

Date of Birth:

Sex:

Male Female

Age:

Grade:

School

Sport(s)

1. Type of disability

2. Date of disability

3. Classification (if available)

4. Cause of disability (birth, disease, accident/trauma, other)

5. List the sports you are interested in playing

6. Do you regularly use a brace, assistive device, or prosthetic?

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 any 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 with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

Yes No

15. Do you have muscle spasticity?

Yes No

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

Yes No

Explain “yes” answers here

Please indicate if you have ever had any of the following.

Atlantoaxial instability

Yes No

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

Signature of athlete

Signature of parent/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 Right:

Vision Left

Corrected

Y N

MEDICAL

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Normal

Abnormal Findings

Eyes/ears/nose/throat

Pupils equal
Hearing

Normal

Abnormal Findings

Lymph nodes

Normal

Abnormal Findings

Heart

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

Normal

Abnormal Findings

Pulses

Simultaneous femoral and radial pulses

Normal

Abnormal Findings

Lungs

Normal

Abnormal Findings

Abdomen

Normal

Abnormal Findings

Genitourinary (males only)b

Normal

Abnormal Findings

Skin

HSV, lesions suggestive of MRSA, tinea corporis

Normal

Abnormal Findings

Neurologic

Normal

Abnormal Findings

MUSCULOSKELETAL

Neck

Normal

Abnormal Findings

Back

Normal

Abnormal Findings

Shoulder/arm

Normal

Abnormal Findings

Elbow/forearm

Normal

Abnormal Findings

Wrist/hand/fingers

Normal

Abnormal Findings

Hip/thigh

Normal

Abnormal Findings

Knee

Normal

Abnormal Findings

Leg/ankle

Normal

Abnormal Findings

Foot/toes

Normal

Abnormal Findings

Functional

Duck-walk, single leg hop

Normal

Abnormal Findings

Consider ECG, 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.

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

(Details)

Not cleared

Pending further evaluation

For any sports

For certain sports

If certain sports, kindly indicate:

Reason

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).

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 of Physician

Date

Address

Phone

Signature of Physician (Indicate if MD or DO)

CLEARANCE FORM

Name

Sex

M F

Age

Date of Birth

Cleared for all sports without restriction

Cleared for all sports without restriction with recommendations for further evaluation or treatment for

(Details)

Not cleared

Pending further evaluation

For any sports

For certain sports

If certain sports, kindly indicate:

Reason

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).

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 of physician

Date

Address

Phone

Signature of physician (Indicate MD or DO)

EMERGENCY INFORMATION

Allergies

Other information

Your information will be encrypted.