Physical Exam-Athletics Department

    Medical Examination For Participation In Interscholastic Athletics

    Medical History-Parent/Guardian please fill out prior to examination.

     

    Student Athlete Name


     

     

    Home Address:

     

     

     

     

    Name of Parent/Guardian

     

     

     

     

    Emergency Contact
    Relationship

     

     

     

    Emergency Contact Address:

     

     

    Sport/Activities Student Will Participate In (CHECK ALL THAT APPLY)

    Sports/Activities
    BaseballFootballCheer/DrillWrestlingBowlingTrack/FieldTennisVolleyballGolfCross countrySoccerSoftballBasketball

     

    Please answer all health history questions on the following page prior to your visit to the doctor. Please fill in the student athlete's personal information (name, gender and birth date) on each page of the form and return the entire packet to the school's athletic department.

    Concussion Management
    A concussion is a disturbance in the function of the brain that can be caused by a blow to the body or head and may occur in any sport or activity. Effects of a concussion may include a variety of symptoms (headache, nausea, dizziness, memory loss, balance problem) with or without a loss of consciousness. I/we understand there is a concussion management protocol established that includes care and return to play criteria.

     

     

    Athletic Pre-Participation Physical Examination Form
    Part A: Health History Form

     

    YesNo 1. Has a doctor ever denied or restricted your participation in sports for any reason?
    YesNo 2. Do you have a ongoing medical condition (like diabetes or asthma)?
    YesNo 3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills?
    YesNo 4. Do you have allergies to medicines, pollen, foods, or stinging insects?
    YesNo 5. Have you ever become dizzy or passed out during or after exercise?
    YesNo 6. Have you ever had discomfort, pain, or pressure in your chest during or after exercise?
    YesNo 7. Do you get more tired than your friends do during exercise?
    YesNo 8. Has a doctor ever told you that you have: High Blood PressureHeart MurmurHeart InfectionHigh Cholesterol (Check all that apply)
    YesNo 9. Has a doctor ever ordered a test for your heart?(for example ECG, echocardiogram)
    YesNo 10. Has anyone in your family ever died for no apparent reason?
    YesNo 11. Does any one in your family have a heart problem?
    YesNo 12. Has a family member or relative died of heart problems or sudden death before the age of 50?
    YesNo 13. Have any of your relatives ever had any one of the following conditions? Hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan's syndrome or long QT Syndrome or a signigicant heart arrhylhmia?
    YesNo 14. Have you ever had racing of your heart or skipped heartbeats?
    YesNo 15. Have you ever spent the night in a hospital
    YesNo 16. Have you ever had surgery?
    Check List Below Q(17-19)
    YesNo 17. Have you ever had an injury, like a sprain, muscle or ligament tear or tendonitis that caused you to miss a practice or game? if yes which affected area below:

    YesNo 18. Have you had any broken or fractured bones or dislocated joints? if yes which affected area below:

    YesNo 19. Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast or crutches? if yes which affected area below:
    HeadNeckShoulderUpper armElbowCalf or ShinHandChestUpper backLower backForearmThighKneeHipAnkleFoot/Toes

    YesNo 20. Have you ever had a stress fracture?
    YesNo 21. Have you ever been told that you have or have had an x-ray for atlantoaxial (neck) instability?
    YesNo 22. Do you regularly use a brace or assistive device
    YesNo 23. Has a doctor ever told you that you have asthma or allergies?
    YesNo 24. Do you cough, wheeze, or have difficulty breathing during or after exercise?
    YesNo 25. Is there anyone in your family with asthma?
    YesNo 26. Have you ever used an inhaler or taken asthma medicine?
    YesNo 27. Were you born without or are you missing a kidney, an eye or testicle, or any other organ?
    YesNo 28. Have you had a severe viral infection such as infectious mononucleosis (mono) or myocarditis in the last month?
    YesNo 29. Do you have any rashes, pressure sores or other skin problems?
    YesNo 30. Have you had a herpes infection?
    YesNo 31. Have you had a head injury or concussion?
    YesNo 32. Have you been hit in the head and been confused or lost your memory?
    YesNo 33. Have you ever had a seizure?
    YesNo 34. Do you have headaches with exercise?
    YesNo 35. Have you ever had numbness or tingling or weakness in your arms, or legs?
    YesNo 36. Have you ever been unable to move your arms or legs after being hit or fallen?
    YesNo 37. When exercising in the heat do you have severe muscle cramps or become ill?
    YesNo 38. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
    YesNo 39. Have you had any problems with your eyes or vision?
    YesNo 40. Do you wear glasses or contact lenses?
    YesNo 41. Do you wear protective eye wear such as googles or a face shield?
    YesNo 42. Are you unhappy with your weight?
    YesNo 43. Are you trying to gain or lose weight?
    YesNo 44. Has anyone recommended you change your weight or eating habits?
    YesNo 45. Do you limit or carefully control what you eat?
    YesNo 46. Do you have concerns that you would like to discuss with the doctor/health care provider?

    Females only:
    YesNo 47. Have you ever had a menstrual period?

     

     

    Explain "Yes" answers here

     

    Athletic Pre-Participation Physical Examination Form
    Part: B Physical Examination

     

    To be completed by the examining physician or provider (PLEASE COMPLETE BOTH PAGES)

     

     

     

     

    Corrected YesNo

    Pupils:

     

    Medical questions:
    Appearance YesNo
    Eyes/ears/nose/throat YesNo
    Hearing YesNo
    Lymph nodes YesNo
    Heart (auscultation should be done supine and standing-abnormal findings require referral for further evaluation) YesNo
    Murmurs YesNo
    Pulses YesNo
    Lungs: Auscultation YesNo
    Abdomen: Assessment(incl, liver, spleen) YesNo
    Genitourinary (males only)YesNo
    Skin YesNo
    Musculoskeletal:
    Neck YesNo
    Back YesNo
    Sholulder/Arm YesNo
    Elbow/Forearm YesNo
    Wrist/Hand/Fingers YesNo
    Hip/Thigh YesNo
    Knee YesNo
    Leg/Ankle YesNo
    Foot/Toes YesNo
    Abnormal Findings

    Does athlete wear contacts? YesNo
    Does athlete require eye protection while playing? YesNo

    Student may participate in the following types of sports (CHECK ALL THAT APPLY):
    All forms of contactContact/CollisionNon-contact/StrenuousLimited contactNon-contact/Non-strenuousStudent cleared for participationStudent cleared for participation pendingStudent not cleared for participation

     

     

    Clearance Form
    Samples of Classification of Sports By Contact:

    (Contact/Collision)
    Field Hockey, Football, Ice Hockey, Lacrosse, Soccer, Wrestling

    (Limited Contact)
    Baseball, Basketball, Cheerleading, Diving, Fencing, Field, High Jump, Pole Vault, Gymnastics, Skiing, Softball, Volleyball

    (Strenuous)
    Discus, Javelin, Shot Put, Rowing, Running/Cross Country, Strength Training, Swimming, Tennis, Track

    (Non-Contact)
    (none)

    (Non-Strenuous)
    Bowling, Golf

    Student may participate in the following types of sports: (CHECK ALL THAT APPLY)
    All forms of contactContact/CollisionNon-contact/StrenuousLimited contactNon-contact/Non-strenuousStudent cleared for participationStudent cleared for participation pendingStudent not cleared for participation

    Athletes Emergency Information
    History of Anaphylaxis? YesNo

     

    Immunizations Up to date

     

    Significant Medical History Information (Please include any history of asthma, hypertension, previous head injury, unequal pupil size etc.)

     

    Does athlete wear contacts? YesNo
    Does athlete require eye protection while playing?
    YesNo

     

    Medical Provider:

     

    Medical providers address: