Preparticipation Physical EvaluationPlease enable JavaScript in your browser to complete this form. - Step 1 of 5HISTORY FORMNote: 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 chartDate of ExamName *Date of birthSexAgeGradeSchoolSport(s)Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently takingDo you have any allergies?YesNoIf yes, please identify specific allergy below.MedicinesPollensFood Stinging InsectsExplain “Yes” answers below. Circle questions you don’t know the answers toGENERAL QUESTIONS1. Has a doctor ever denied or restricted your participation in sports for any reason? YesNo 2. Do you have any ongoing medical conditions? If so, please identify below:AsthmaAnemiaDiabetesInfectionsOther3. Have you ever spent the night in the hospital?YesNo4. Have you ever had surgery?YesNoHEART HEALTH QUESTIONS ABOUT YOU5. Have you ever passed out or nearly passed out DURING or AFTER exercise?YesNo6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?YesNo7. Does your heart ever race or skip beats (irregular beats) during exercise?YesNo8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:High blood pressureKawasaki disease High cholesterol A heart murmurA heart infectionOther:9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) YesNo10. Do you get lightheaded or feel more short of breath than expected during exercise?YesNo11. Have you ever had an unexplained seizure?YesNo12. Do you get more tired or short of breath more quickly than your friends during exercise? YesNoHEART HEALTH QUESTIONS ABOUT YOUR FAMILY13. 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)?YesNo14. 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?YesNo15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?YesNo16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?YesNoNextBONE AND JOINT QUESTIONS17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? YesNo18. Have you ever had any broken or fractured bones or dislocated joints? YesNo19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?YesNo20. Have you ever had a stress fracture?YesNo21. 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)YesNo22. Do you regularly use a brace, orthotics, or other assistive device?YesNo23. Do you have a bone, muscle, or joint injury that bothers you?YesNo24. Do any of your joints become painful, swollen, feel warm, or look red?YesNo25. Do you have any history of juvenile arthritis or connective tissue disease?YesNoMEDICAL QUESTIONS26. Do you cough, wheeze, or have difficulty breathing during or after exercise? YesNo27. Have you ever used an inhaler or taken asthma medicine?YesNo28. Is there anyone in your family who has asthma?YesNo29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?YesNo30. Do you have groin pain or a painful bulge or hernia in the groin area?YesNo31. Have you had infectious mononucleosis (mono) within the last month? YesNo32. Do you have any rashes, pressure sores, or other skin problems? YesNo33. Have you had a herpes or MRSA skin infection? YesNo34. Have you ever had a head injury or concussion? YesNo35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?YesNo36. Do you have a history of seizure disorder? YesNo37. Do you have headaches with exercise?YesNo38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? YesNo39. Have you ever been unable to move your arms or legs after being hit or falling?YesNo40. Have you ever become ill while exercising in the heat?YesNo41. Do you get frequent muscle cramps when exercising?YesNo42. Do you or someone in your family have sickle cell trait or disease? YesNo43. Have you had any problems with your eyes or vision?YesNo44. Have you had any eye injuries?YesNo45. Do you wear glasses or contact lenses? YesNo46. Do you wear protective eyewear, such as goggles or a face shield?YesNo47. Do you worry about your weight? YesNo48. Are you trying to or has anyone recommended that you gain or lose weight? YesNo49. Are you on a special diet or do you avoid certain types of foods? YesNo50. Have you ever had an eating disorder? YesNo51. Do you have any concerns that you would like to discuss with a doctor?YesNoFEMALES ONLY52. Have you ever had a menstrual period?YesNo53. How old were you when you had your first menstrual period? YesNo54. How many periods have you had in the last 12 months?YesNoExplain “yes” answers hereI hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athleteClear SignatureSignature of parent/guardian Clear SignatureDate NextTHE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORMDate of ExamName *Date of birthSexAgeGradeSchoolSport(s)1. Type of disability2. Date of disability3. Classification (if available)4. Cause of disability (birth, disease, accident/trauma, other)5. List the sports you are interested in playing6. Do you regularly use a brace, assistive device, or prosthetic?YesNo7. Do you use any special brace or assistive device for sports? YesNo8. Do you have any rashes, pressure sores, or any other skin problems? YesNo9. Do you have a hearing loss? Do you use a hearing aid? YesNo10. Do you have a visual impairment? YesNo11. Do you use any special devices for bowel or bladder function? YesNo12. Do you have burning or discomfort when urinating? YesNo13. Have you had autonomic dysreflexia? YesNo14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness? YesNo15. Do you have muscle spasticity? YesNo16. Do you have frequent seizures that cannot be controlled by medication? YesNoExplain “yes” answers herePlease indicate if you have ever had any of the following. Atlantoaxial instabilityYesNoX-ray evaluation for atlantoaxial instabilityYesNoDislocated joints (more than one)YesNoEasy bleedingYesNoEnlarged spleenYesNoHepatitisYesNoOsteopenia or osteoporosisYesNoDifficulty controlling bowelYesNoDifficulty controlling bladderYesNoNumbness or tingling in arms or handsYesNoNumbness or tingling in legs or feetYesNoWeakness in arms or handsYesNoWeakness in legs or feetYesNoRecent change in coordinationYesNoRecent change in ability to walkYesNoSpina bifidaYesNoLatex allergyYesNoExplain “yes” answers hereI hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.Signature of athlete Clear Signature Signature of parent/guardian Clear SignatureDate NextPHYSICAL EXAMINATION FORMName *Date PHYSICIAN REMINDERS1. 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).EXAMINATIONHeightWeightMultiple ChoiceMaleFemaleBPPulseVision R 20/L 20/CorrectedYNMEDICALAppearance • Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)NORMALABNORMAL FINDINGSEyes/ears/nose/throat • Pupils equal • HearingNORMAL 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 pulsesNORMAL ABNORMAL FINDINGS LungsNORMAL ABNORMAL FINDINGS Abdomen NORMAL ABNORMAL FINDINGS Genitourinary (males only) NORMAL ABNORMAL FINDINGS Skin • HSV, lesions suggestive of MRSA, tinea corporisNORMAL ABNORMAL FINDINGS Neurologic c NORMAL ABNORMAL FINDINGS MUSCULOSKELETALNeckNORMALABNORMAL FINDINGS BackNORMAL ABNORMAL FINDINGS Shoulder/armNORMAL ABNORMAL FINDINGS Elbow/forearm NORMAL ABNORMAL FINDINGS Wrist/hand/fingers NORMAL ABNORMAL FINDINGS Hip/thigh NORMAL ABNORMAL FINDINGSKneeNORMAL ABNORMAL FINDINGS Leg/ankle NORMALABNORMAL FINDINGSFoot/toes NORMALABNORMAL FINDINGSFunctional • Duck-walk, single leg hop NORMALABNORMAL FINDINGSaConsider 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.CheckboxesCleared for all sports without restrictionCleared for all sports without restriction with recommendations for further evaluation or treatment forSingle Line TextCheckboxesNot cleared Pending further evaluationFor any sports For certain sportsSingle Line TextReasonRecommendations 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 examAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneSignature of physician, APN, PAClear SignatureNextCLEARANCE FORMName *SexMFAgeDate of birthCheckboxesCleared for all sports without restrictionCleared for all sports without restriction with recommendations for further evaluation or treatment forNot cleared Pending further evaluationFor any sports For certain sportsSingle Line TextReasonRecommendationsEMERGENCY INFORMATIONAllergiesOther informationHCP OFFICE STAMPSCHOOL PHYSICIANREVIEWED ON ApprovedNot approvedSignatureClear SignatureI 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 AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneSignature of physician, APN, PAClear SignatureCompleted Cardiac Assessment Professional Development Module Date SignatureClear SignatureSubmit