Medical Examination For Participation In Interscholastic Athletics

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

Student Athlete Name

Last Name
First Name

M.I.

Home Address:
Street:
City:

State:
Zip:

Grade:
DOB:

Age:

Name of Parent/Guardian
Street:
City:

State:
Zip:

Phone:
Work:

Cell:
Parent/Guardians email

Emergency Contact
Name
Relationship

Phone:
Work:

Cell:

Emergency Contact Address:
Street:
City:

State:
Zip:

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

Sports/Activities
BaseballFootballCheer/DrillWrestlingBowlingTrack/FieldTennisVolleyballGolfCross countrySoccerSoftballBasketball
Other

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.

Athlete signature
Date

Legal parent/guardian signature
Date

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

Student athlete name
Gender

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

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

Explain "Yes" answers here

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

Athletes name

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

Height
Weight

BMI %ILE(Per CDC %ile charts)
Pulse:

Blood pressure:
Blood pressure %ILE(Per NIH Guidelines)

Vision R20/
L20/

Corrected YesNo

Pupils:
Equal
Unequal

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

Name of Physician/Provider
Date

Signature of Physician/Provider
Student's primary Physician/Provider (for follow up, if necessary)

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
Allergies
History of Anaphylaxis? YesNo

Immunizations Up to date
Last Tetanus immunization

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

Student's primary Physician/Provider (for follow up, if necessary)

Current Medical Conditions:

Current Medications (if on asthma medication please indicate if needed prior to sports):

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

Medical Provider:
Name
Phone:

Medical providers address:
Street:
City:

State:
Zip:

Signature of Medical provider
Date: