Initial Physical Exam Form Page 3
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3Pre-Participation Physical Evaluation
Health History
Date of Exam___________________
Name____________________________________________________________Age___________Sex___________Date of Birth_________________________________
Grade__________School___________________________________________Sport(s)__________________________________________________________________
Address__________________________________________________City_________________________________State__________Phone________________________
Personal Physician_______________________________________________________________________________________
In case of emergency, contact:
Name____________________________________________Relationship_________________________Phone(H)____________________Phone(W)________________
Explain "Yes" answers below
Circle questions you don't know the answers to
Yes No
Yes No
10. Do you have any special or corrective equipment or
1. Have you had a medical illness or injury since your last check-up or
devices that aren't usually used for your sport or position
sports physical?
(examples: knee brace, special neck roll, foot orthotics,
●
Do you have an on-going or chronic illness?
retainer on your teeth, hearing aid, etc.)
2. Have you ever been hospitalized overnight?
11. Have you had any problems with your eyes or vision?
●
Have you ever had surgery?
●
Do you wear glasses, contacts, or protective eyewear?
3. Are you currently taking any prescription or non-prescription (over the
12. Have you ever had a sprain, strain or swelling after injury?
Have you broken or fractured any bones or dislocated any
counter) medications or pills or using an inhaler?
●
joints?
●
Have you ever taken any supplements or vitamins to help you gain or
Have you had any other problems with pain or swelling in
lose weight or improve your performance?
●
4. Do you have any allergies (for example, to pollen, medicine, food or
muscles, tendons, bones or joints?
stinging insects)?
If yes, check appropriate box and explain below.
Head
Elbow
Hip
●
Have you ever had a rash or hives develop during or after execise?
Neck
Forearm
Thigh
5. Have you ever passed out during or after exercise?
Chest
Wrist
Knee
●
Have you ever been dizzy during or after exercise?
Shoulder
Hand
Shin/calf
●
Have you ever had chest pain during or after exercise?
Upper Arm
Finger
Ankle
●
Do you get tired more quickly than your friends do during exercise?
Foot
●
Have you ever had racing of your heart or skipped heartbeats?
●
Have you had high blood pressure or high cholesterol?
13. Do you want to weigh more or less than you do now?
●
Have you ever been told you have a heart murmur?
●
Do you lose weight regularly to meet weight requirements for
●
Has any family member or relative died of heart problems or of sudden
your sport?
death before age 50?
14. Do you feel stressed out?
●
Have you had a severe viral infection (for example, myocarditis or
15. Record the dates of your most recent immunizations:
mononucleosis) within the last month?
Tetanus______________________ Measles______________________
●
Has a physician ever denied or restricted your participation in sports for
Hepatitis B___________________ Chickenpox___________________
any heart problems?
FEMALES ONLY
6. Do you have any current skin problems (for example, itching, rashes,
16. When was your first menstrual period?____________________________
acne, warts, fungus, or blisters)?
When was your most recent menstrual period?_____________________
7. Have you ever had a head injury or concussion?
How much time do you usually have from the start of one period to the
start of another?_____________________________________________
●
Have you ever been knocked out, become unconcious, or lost your
How many periods have you had in the last year?__________________
memory?
What was the longest time between periods in the last year?__________
●
Have you ever had a seizure?
●
Do you have frequent or severe headaches?
●
EXPLAIN ANY YES ANSWERS HERE
Have you ever had numbness or tingling in your arms, hands, legs or
feet?
●
Have you ever had a stinger, burner, or pinched nerve?
8. Have you ever become ill from exercising in the heat?
9. Do you cough, wheeze, or have trouble breathing during or after activity
●
Do you have asthma?
●
Do you have seasonal allergies that require medical treatment?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Student__________________________________________ Signature of Parent____________________________________ Date____________________
Form B, Updated September, 2011
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