Preparticipation Physical Evaluation - Medical History
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1
2P
P
E
-- M
H
REPARTICIPATION
HYSICAL
VALUATION
EDICAL
ISTORY
REVISED 12-4-14
This M
H
F
must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These
EDICAL
ISTORY
ORM
questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student's Name: (print)
Sex
Age
Date of Birth
Address
Phone
Grade
School
Personal Physician
Phone
In case of emergency, contact:
Name
Relationship
Phone (H)
(W)
Explain “Yes” answers in the box below**. Circle questions you don’t know the answers to.
Yes
No
Yes
No
1. Have you had a medical illness or injury since your last check
o
o
o
13.
Have you ever gotten unexpectedly short of breath with
o
up or sports physical?
exercise?
2.
Have you been hospitalized overnight in the past year?
o
o
o
o
Do you have asthma?
Have you ever had surgery?
o
o
Do you have seasonal allergies that require medical treatment?
o
o
3. Have you ever had prior testing for the heart ordered by a
o
o
14.
Do you use any special protective or corrective equipment or
o
o
physician?
devices that aren't usually used for your sport or position (for
Have you ever passed out during or after exercise?
o
o
example, knee brace, special neck roll, foot orthotics, retainer
Have you ever had chest pain during or after exercise?
o
o
on your teeth, hearing aid)?
Do you get tired more quickly than your friends do during
o
o
15.
Have you ever had a sprain, strain, or swelling after injury?
o
o
exercise?
Have you broken or fractured any bones or dislocated any
o
o
Have you ever had racing of your heart or skipped heartbeats?
o
o
joints?
Have you had high blood pressure or high cholesterol?
Have you had any other problems with pain or swelling in
o
o
o
o
Have you ever been told you have a heart murmur?
o
o
muscles, tendons, bones, or joints?
Has any family member or relative died of heart problems or of
o
o
If yes, check appropriate box and explain below:
sudden unexpected death before age 50?
Has any family member been diagnosed with enlarged heart,
o
o
o Head
o Elbow
o Hip
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
o Neck
o Forearm
o Thigh
QT syndrome or other ion channelpathy (Brugada syndrome,
o
o
o Back
o Wrist
o Knee
etc), Marfan's syndrome, or abnormal heart rhythm?
o Chest
o Hand
o Shin/Calf
Have you had a severe viral infection (for example,
o
o
o Shoulder
o Finger
o Ankle
myocarditis or mononucleosis) within the last month?
o Upper Arm
o Foot
Has a physician ever denied or restricted your participation in
o
o
16.
Do you want to weight more or less than you do now?
o
o
sports for any heart problems?
17.
Do you feel stressed out?
o
o
Have you ever had a head injury or concussion?
o
o
4.
18.
Have you ever been diagnosed with or treated for sickle cell
o
o
.
o
o
Have you ever been knocked out, become unconscious, or lost
trait or cell disease?
4
your memory?
Females
only
If yes, how many times? __________
19. When was your first menstrual period? _____________
When was your last concussion? __________
When was your most recent menstrual period? _____________
How severe was each one? (Explain below)
Have you ever had a seizure?
o
o
How much time do you usually have from the start of one period to the start of
Do you have frequent or severe headaches?
o
o
another? _____________
o
o
Have you ever had numbness or tingling in your arms, hands,
o
o
How many periods have you had in the last year? _____________
legs or feet?
What was the longest time between periods in the last year? _____________
Have you ever had a stinger, burner, or pinched nerve?
o
o
5. Are you missing any paired organs?
o
o
An individual answering in the affirmative to any question relating to a possible cardiovascular health
6. Are you under a doctor’s care?
o
o
issue (question three above), as identified on the form, should be restricted from further participation
7. Are you currently taking any prescription or non-prescription
o
o
unt
i
l
t
he
i
ndi
vidual is examined and cleared by a physician, physician assistant, chiropractor, or nurse
(over-the-counter) medication or pills or using an inhaler?
pr
a
c
t
iti
o
ne
r.
8. Do you have any allergies (for example, to pollen, medicine,
o
o
**EXPLAIN ‘YES’ ANSWERS IN THE BOX BELOW (attach another sheet if necessary):
food, or stinging insects)?
___________________________________________________________________________
9. Have you ever been dizzy during or after exercise?
o
o
___________________________________________________________________________
10. Do you have any current skin problems (for example, itching,
o
o
___________________________________________________________________________
rashes, acne, warts, fungus, or blisters)?
__________
11. Have you ever become ill from exercising in the heat?
o
o
12. Have you had any problems with your eyes or vision?
o
o
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League
nor the school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and
consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the
school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.
If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify the school authorities of such
illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could
subject the student in question to penalties determined by the UIL
Student Signature:
Parent/Guardian Signature:
Date:
Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician
T
assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches.
HIS FORM MUST BE ON FILE PRIOR TO
,
,
.
PARTICIPATION IN ANY PRACTICE
SCRIMMAGE OR CONTEST BEFORE
DURING OR AFTER SCHOOL
For School Use Only:
This Medical History Form was reviewed by: Printed Name
Date
Signature
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