PREPARTICIPATION PHYSICAL EVALUATION

Please correct the errors described below.

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.)

Medicine and Allergies:

Explain "Yes" answers below. Circle questions you don't know the answers to.

General Questions

HEART HEALTH QUESTIONS ABOUT YOU

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

MEDICAL QUESTIONS

FEMALES ONLY

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

The Athlete with Special Needs: Supplement History Form

Please indicate if you have aver had any at the following.

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

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

Medical

Appearance

  • Marfan stigmata (kyphoscoliosis, high-arched palate, pastas excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MAP, aortic insufficiency)
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Lymph nodes

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

  • Simultaneous femoral and radial pulses
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Skin:

  • HSV, lesions suggestive of MRSA, tinea corporis
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MUSCULOSKELETAL

Functional

  • Duck-walk, Single leg hop
  • Item 2
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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 at the physical exam is on record in my office and can be made available to the school at the request of the parents. II 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).

Clearance Form

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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 at the physical exam is on record in my office and can be made available to the school at the request of the parents. II 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).

Emergency Information

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