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Explain “Yes” answers below. Circle questions you don’t know the answers to. Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have an ongoing medical condition (like diabetes or asthma)? 3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills? 4. Do you have allergies to medicines, pollens, foods, or stinging insects? 5. Have you ever passed out or nearly passed out DURING exercise? 6. Have you ever passed out or nearly passed out AFTER exercise? 7. Have you ever had discomfort, pain, or pressure in your chest during exercise? 8. Does your heart race or skip beats during exercise? 9. Has a doctor ever told you that you have (check all that apply): ■ High blood pressure ■ A heart murmur ■ High cholesterol ■ A heart infection 10. Has a doctor ever ordered a test for your heart? (for example, ECG, echocardiogram) 11. Has anyone in your family died for no apparent reason? 12. Does anyone in your family have a heart problem? 13. Has any family member or relative died of heart problems or of sudden death before age 50? 14. Does anyone in your family have Marfan 15. Have you ever spent the night in a hospital? 16. Have you ever had surgery? 17. Have you ever had an injury, like a sprain, muscle or ligament tear or tendinitis, that caused you to miss a practice or game? If yes, circle affected area below: 18. Have you had any broken or fractured bones, or dislocated joints? If yes, circle below: 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, circle below: 20. Have you ever had a stress fracture? 21. Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability? 22. Do you regularly use a brace or assistive device? 23. Has a doctor ever told you that you have asthma or allergies? 24. Do you cough, wheeze, or have difficulty breathing during or after exercise? 25. Is there anyone in your family who has asthma? 26. Have you ever used an inhaler or taken asthma medicine? 27. Were you born without or are you missing a kidney, an eye, a testicle, or any other organ? 28. Have you had infectious mononucleosis (mono) within the last month? 29. Do you have any rashes, pressure sores, or other skin problems? 30. Have you had a herpes skin infection? 31. Have you ever had a head injury or concussion? 32. Have you been hit in the head and been confused or lost your memory? 33. Have you ever had a seizure? 34. Do you have headaches with exercise? 35. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? 36. Have you ever been unable to move your arms or legs after being hit or falling? 37. When exercising in the heat, do you have severe muscle cramps or become ill? 38. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease? 39. Have you had any problems with your eyes or vision? 40. Do you wear glasses or contact lenses? 41. Do you wear protective eyewear, such as goggles or a face shield? 42. Are you happy with your weight? 43. Are you trying to gain or lose weight? 44. Has anyone recommended you change your weight or eating habits? 45. Do you limit or carefully control what you eat? 46. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY 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 year? Explain “Yes” answers here: Preparticipation Physical Evaluation DATE OF I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of Signature of parent/guardian Date ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ © 2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Sex Age Date of Grade____ School Address Personal In case of emergency, contact Name Relationship Phone ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Head Neck Shoulder Upper Elbow Forearm Hand/ Chest arm fingers Upper Lower Hip Thigh Knee Calf/shin Ankle Foot/toes back back Yes No HISTORY FORM ---PAGE BREAK--- Follow-Up Questions on More Sensitive Issues 1. Do you feel stressed out or under a lot of pressure? 2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days? 3. Do you feel safe? 4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke? 5. During the past 30 days, did you use chewing tobacco, snuff, or dip? 6. During the past 30 days, have you had at least 1 drink of alcohol? 7. Have you ever taken steroid pills or shots without a doctor's prescription? 8. Have you ever taken any supplements to help you gain or lose weight or improve your performance? 9. Questions from the Youth Risk Behavior Survey on guns, seatbelts, unprotected sex, domestic violence, drugs, etc Notes: Preparticipation Physical Evaluation PHYSICAL EXAMINATION FORM NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL Appearance Eyes/ears/nose/throat Hearing nodes Heart Murmurs Pulses Lungs Abdomen Genitourinary† Skin MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Name of physician Date Address Phone Signature of MD or DO *Multiple-examiner set-up only. †Having a third party present is recommended for the genitourinary examination. © 2004 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Name of birth Height Weight % Body fat (optional) Pulse_______ , Vision R 20/ L 20/ Corrected: Y N Pupils: Equal Unequal Yes No ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Notes: ---PAGE BREAK--- Cleared without restriction Cleared, with recommendations for further evaluation or treatment for: Not cleared for All sports Certain sports: Reason: Recommendations: Name of physician (print/type) Date Address Signature of physician MD or DO Preparticipation Physical Evaluation Sex Age Date of CLEARANCE FORM EMERGENCY INFORMATION Allergies Other Information IMMUNIZATIONS (eg,tetanus/diphtheria; measles, mumps, rubella; hepatitis A, B; influenza; poliomyelitis; pneumococcal; meningococcal; varicella) Up to date (see attached documentation) Not up to date Specify © 2004 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.