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

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

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