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
HEART HEALTH QUESTIONS ABOUT YOU
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
BONE AND JOINT QUESTIONS
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
PHYSICAL EXAMINATION FORM
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).
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
• Pupils equal
• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)
• Simultaneous femoral and radial pulses
Genitourinary (males only)
• HSV, lesions suggestive of MRSA, tinea corporis
• Duck-walk, single leg hop
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.
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).