Tma/tssaa Preparticipation Medical Evaluation Form printable pdf download

TMA/TSSAA Preparticipation Medical Evaluation Form

This page to be filled out completely by the student-athlete and their parent or guardian.

Name: _________________________________

Sex:Ì M Ì F Age:____ Date of Birth:_________

Grade: 9 1 0 1 1 1 2 School:_____________________________ Sport: ____________________

Home Address:_____________________________________________________________________

City:_________________________________ State:_________ Zip:__________________________

Father’s Name: ________________________ Home Phone:____________ Work Phone:__________

Mother’s Name: ________________________ Home Phone:____________ Work Phone:__________

Another Person to contact: ____________________Relationship: ___________Phone#____________

Personal Physician:___________________________ Health Insurance Name: ___________________

Have you ever had a pre-participation physical before? ÌYes ÌNo

If so, when/where?___________________________________________________________________

Please explain Yes answers below. If the questions do not pertain to you , simply ignore them.

Yes

Have you ever been hospitalized?

Have you ever had surgery?

Are you presently taking any medication or pills?

Do you have any allergies (medicine, bees, or other stinging insects)?

Have you ever passed out during exercise?

Have you ever been dizzy during or after exercise?

Have you ever had chest pain during or after exercise?

Do you tire more quickly than your friends during exercise?

Have you ever had high blood pressure?

Have you ever been told that you have a heart murmur?

Have you ever had a racing of your heart or skipped heartbeats?

Has anyone in your family died of heart problems or a sudden death before the age of 50

Do you have any skin problems (itching, rash, acne)?

Have you ever had a head injury?

Have you ever been knocked out or unconscious?

Have you ever had a seizure?

Have you ever had a “stinger”, “burner”, or pinched nerve?

Have you ever had heat or muscle cramps?

Do you have trouble breathing or do you cough during or after activities?

Do you use any special equipment (pads, braces, neck roll, mouth guard, eye guard)?

10.

Have you had any problems with your eyes or vision?

Do you wear glasses or contacts or protective eye wear?

11.

Have you ever had any other medical problems (such as infectious mononucleosis, diabetes)?

12.

Have you had any medical problem since your last evaluation?

13.

Have you ever sprained/strained, dislocated, broken, or had repeated swelling of any bones or joints?

Head

Shoulder

Thigh

Neck

Elbow

Knee

Chest

Forearm

Shin/Calf

Back

Wrist

Ankle

Hip

Hand

14.

When was your last tetanus shot?________________________________

When was your last measles immunization?________________________

15.

Females only:

When was your first menstrual period?____________________ Your last period?___________________

What was the longest time between your periods last year?____________________________________

Please explain yes answers here:

To the best of my knowledge, my answers to the above questions are correct. As parent/guardian of the student-athlete whose name appears at the top of this page

and whose signature is found below, I recognize the potential dangers inherent to interscholastic athletics and give my permission for full participation. In the event

of an emergency, I herein give my permission for treatment by any qualified health care practitioner and that the information contained in this form can be released

to any physician or health care facility administering emergency care and to representatives of Blount Memorial Total Rehabilitation/Maryville Orthopedic Clinic to

discuss these matters with the athlete’s coach.

Signature of Parent/Guardian

Date

Signature of Athlete

Date