IHSA Pre-participation Examination

To be completed by athlete or parent prior to examination.

Last Name:

First Name:

Middle Name:

School Year:

Address:

City/State:

Phone No.:

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-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies? If yes, please identify specific allergy below.

Yes No

Check all that apply:

Medicines

Pollens

Food

Stinging Insects

Explain “Yes” answers below.

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 lightheaded 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 QT 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 history 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 eating 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.

Signature of athlete:

Signature of parent/guardian:

Date:

PHYSICAL EXAMINATION FORM (for office use)

EXAMINATION

Height:

Weight:

Gender:

Male Female

BP:

Short text field

Vision R 20/

L 20/

Corrected:

Yes No

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

Normal:

Abnormal Findings:

• Hearing

Normal:

Abnormal Findings:

Lymph nodes

Normal:

Abnormal Findings:

Heart
• Murmurs (auscultation standing, supine, +/- Valsalva)

Normal:

Abnormal Findings:

• 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)

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:

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 Signature:

Physician’s Assistant Signature*:

Advanced Nurse Practitioner’s 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 to penalties 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

Signature of student-athlete:

Date:

Signature of parent-guardian:

Date:

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

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