Pre-Participation Physical Evaluation

1 (PRINT OR TYPE) PHYSICIANS STAMP: 1997 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine *Station-based examination onlyPre- participation Physical Evaluation (This page to be completed by physician/nurse practitioner/physician assistant) Physical EXAMINATIONDATE OF EXAM _____NAME _____DATE OF BIRTH _____HEIGHT _____ WEIGHT _____ % BODY FAT (optional) _____ PULSE _____ BP _____VISION R 20/ _____ L 20/ _____ CORRECTED? Y _____ N _____ PUPILS: EQUAL _____ UNEQUAL _____NORMALABNORMAL FINDINGINITIALS *MEDICALA ppearance _____Eyes/Ears/Nose/Throat _____Lymph nodes _____Heart _____Pulses _____Lungs _____Abdomen _____Genitalia (males only) _____Skin _____MUSCULOSKELETALNeck _____Back _____Shoulder/Arm _____Elbow/Forearm _____Wrist/Hand _____Hip/Thigh _____Knee _____Leg/Ankle _____Foot _____CLEARANCEqClearedqCleared after completing Evaluation /rehabilitation for: _____qNot cleared for [Sport(s)]: _____ Reason: _____Recommendation: _____Name of physician/nurse practitioner/physician assistant _____ Date: _____Address: _____ Phone.

2 _____Signature of physician/nurse practitioner/physician assistant _____Endorsed by the MPSSAAPre- participation Physical EvaluationHISTORYThis page to be completed by student and parent/guardianName _____ Sex _____ Age _____ Date of Birth _____Grade _____ School _____ Sport(s) _____Address _____Personal physician _____In case of emergency, contactName _____ Relationship _____ Phone (H) _____ (W) _____1. Have you had a medical illness or injury sinceqqyour last check up or sports Physical ?Do you have an ongoing or chronic illness?qq2. Have you ever been hospitalized overnight?qqHave you ever had surgery?qq3. Are you currently taking any prescription orqqnonprescription (over-the-counter) medications orpills or using an inhaler?Have you ever taken any supplements or vitaminsqqto help you gain or lose weight or improve yourperformance?

3 4. Do you have any allergies (for example, to pollen,qqmedicine, food, or stinging insects)?Have you ever had a rash or hives develop duringqqor after exercise?5. Have you ever passed out during or after exercise?qqHave you ever been dizzy during or after exercise?qqHave you ever had chest pain during or after exercise?qqDo you get tired more quickly than your friends doqqduring exercise?Have you ever had racing of your heart or skippedqqheartbeats?Have you had high blood pressure or high cholesterol?qqHave you ever been told you have a heart murmur?qqHas any family member or relative died of heartqqproblems or of sudden death before age 50?Have you had a severe viral infection (for example,qqmyocarditis or mononucleosis) within the last month?Has a physician ever denied or restricted yourqqparticipation in sports for any heart problems?

4 6. Do you have any current skin problems (for example,qqitching, rashes, acne, warts, fungus, or blisters)?7. Have you ever had a head injury or concussion?qqHave you ever been knocked out, become unconscious,qqor lost your memory?Have you ever had a seizure?qqDo you have frequent or severe headaches?qqHave you ever had numbness or tingling in your arms,qqhands, legs, or feet?Have you ever had a stinger, burner, or pinched nerve?qq8. Have you ever become ill from exercising in the heat?qq9. Do you cough, wheeze, or have trouble breathingqqduring or after activity?Do you have asthma?qqDo you have seasonal allergies that require medicalqqtreatment?10. Do you use any special protective or correctiveqqequipment or devices that aren t usually used for your sportor position (for example, knee brace, special neck roll,foot orthotics, retainer on your teeth, hearing aid)?

5 11. Have you had any problems with your eyes or vision?qqDo you wear glasses, contacts, or protective eyewear?qq12. Have you ever had a sprain, strain, or swelling after injury?qqHave you broken or fractured any bone, or dislocatedqqany joints?Have you had any other problems with pain or swellingqqin muscles, tendons, bones, or joints?If yes, check appropriate box and explain armqHandqKneeqBackqElbowqFingerqShin/cal fqChestqForearmqHipqAnkleqShoulderqWrist qThighqFoot13. Do you want to weigh more or less than you do now?qqDo you lose weight regularly to meet weight requirementsqqfor your sport?14. Do you feel stressed out?qq15. Record the dates of your most recent immunizations (shots) for:Tetanus _____ Measles _____Hepatitis B _____ Chickenpox _____FEMALES ONLY16. When was your first menstrual period?

6 _____When was your most recent menstrual period? _____How much time do you usually have from the start of one period to thestart of another? _____How many periods have you had in the last year? _____What was the longest time between periods inthe last year? _____Explain Yes answers here: _____We hereby state that, to the best of our knowledge, our answers to the above questions are complete and of athlete _____ Signature of parent/guardian _____ Date _____ 1997 American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports MedicineYESNOYESNOE xplain Ye s answers below. Circle questions if you don t know the answers.