Preparticipation Physical Evaluation Preview

Preparticipation Physical Evaluation

- Step 1 of 5

HISTORY FORM

Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keepa copy of this form in the chart

Date of Exam

Name *

Date of birth

Sex

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?

If yes, please identify specific allergy below.

Medicines
Pollens
Food
Stinging Insects

Explain “Yes” answers below. Circle 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?

2. Do you have any ongoing medical conditions? If so, please identify below:

Asthma
Anemia
Diabetes
Infections

Other

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

4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU

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

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

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

8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:

High blood pressure
Kawasaki disease
High cholesterol
A heart murmur
A heart infection

Other:

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

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

11. Have you ever had an unexplained seizure?

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

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)?

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?

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

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

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?

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

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

20. Have you ever had a stress fracture?

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)

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

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

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

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

MEDICAL QUESTIONS

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

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

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

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

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

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

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

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

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

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

36. Do you have a history of seizure disorder?

37. Do you have headaches with exercise?

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

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

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

41. Do you get frequent muscle cramps when exercising?

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

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

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

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

47. Do you worry about your weight?

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

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

50. Have you ever had an eating disorder?

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

FEMALES ONLY

52. Have you ever had a menstrual period?

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

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

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

THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM

Date of Exam

Name *

Date of birth

Sex

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?

7. Do you use any special brace or assistive device for sports?

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

9. Do you have a hearing loss? Do you use a hearing aid?

10. Do you have a visual impairment?

11. Do you use any special devices for bowel or bladder function?

12. Do you have burning or discomfort when urinating?

13. Have you had autonomic dysreflexia?

14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness?

15. Do you have muscle spasticity?

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

Explain “yes” answers here

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

Atlantoaxial instability

X-ray evaluation for atlantoaxial instability

Dislocated joints (more than one)

Easy bleeding

Enlarged spleen

Hepatitis

Osteopenia or osteoporosis

Difficulty controlling bowel

Difficulty controlling bladder

Numbness or tingling in arms or hands

Numbness or tingling in legs or feet

Weakness in arms or hands

Weakness in legs or feet

Recent change in coordination

Recent change in ability to walk

Spina bifida

Latex allergy

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

Name *

Date

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

Multiple Choice

Male
Female

Pulse

Vision R 20/

L 20/

Corrected

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)

NORMAL

ABNORMAL FINDINGS

Skin • HSV, lesions suggestive of MRSA, tinea corporis

NORMAL

ABNORMAL FINDINGS

Neurologic c

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

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
bConsider GU exam if in private setting. Having third party present is recommended.
cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

Checkboxes

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

Single Line Text

Checkboxes

Not cleared
Pending further evaluation
For any sports
For certain sports

Single Line Text

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, a physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians).

Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type) *

Date of exam

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Signature of physician, APN, PA

CLEARANCE FORM

Name *

Sex

Age

Date of birth

Checkboxes

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

Not cleared
Pending further evaluation
For any sports
For certain sports

Single Line Text

Reason

Recommendations

EMERGENCY INFORMATION

Allergies

Other information

HCP OFFICE STAMP

SCHOOL PHYSICIAN

REVIEWED ON

Approved
Not approved

Signature

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)

Name of physician, advanced practice nurse (APN), physician assistant (PA) *

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Signature of physician, APN, PA

Completed Cardiac Assessment Professional Development Module

Date

Signature

Call Today

(856) 848-8060

1132 Cooper St, Deptford, NJ 08096, United States

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1132 Cooper St, Deptford, NJ 08096, United States

HISTORY FORM

GENERAL QUESTIONS

HEART HEALTH QUESTIONS ABOUT YOU

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

BONE AND JOINT QUESTIONS

MEDICAL QUESTIONS

FEMALES ONLY

THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM

PHYSICAL EXAMINATION FORM

PHYSICIAN REMINDERS

EXAMINATION

MEDICAL

MUSCULOSKELETAL

CLEARANCE FORM

EMERGENCY INFORMATION

SCHOOL PHYSICIAN

Call Today

1132 Cooper St, Deptford, NJ 08096, United States

Schedule a Virtual Appointment

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