Confidential Athletic Pre-Participation Physical Examination Form (Page 2 of 3) in pdf

MHSA CONFIDENTIAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION

See Montana High School Association, Article II, Section (3), Physical Exam. A physical examination is required for each student in order to be considered

eligible for participation in an Association contest. Physical examinations must be completed prior to the first practice. This examination must be certified by

a licensed medical professional acting within the scope and limitations of his/her practice. This certification is valid for a period of one school year. A

physical examination conducted before May 1

is not valid for participation for the following school year. All information is to remain

confidential.

HISTORY – To be completed by the student and parent(s).

QUESTIONNAIRE FOR ATHLETIC PARTICIPATION (PLEASE PRINT)

Grade

Date of Birth

Name

Male

Female

Home Address

Phone Number

Parent’s Name

Family Physician

Current School

Date

Student Signature

Yes No

Explain “Yes” answers below. Circle questions to which

25. Do you cough, wheeze, or have difficulty breathing during or after

c c

you don’t know the answer.

Yes No

exercise?

26. Is there anyone in your family who has asthma?

c c

1. Has a doctor ever denied or restricted your participation in sports for

27. Have you ever used an inhaler or taken asthma medicine?

c c

any reason?

28. Were you born without or are you missing a kidney, an eye, a testicle, c c

2. Do you have an ongoing medical condition (like diabetes or asthma)?

or any other organ?

c c

3. Are you currently taking any prescription or nonprescription

29. Have you had infectious mononucleosis (mono) within the last month? c c

c c

(over-the-counter) medicines or pills?

30. Do you have any rashes, pressure sores, or other skin problems?

c c

4. Are you taking medicine for ADHD?

31. Have you had a herpes skin infection?

c c

5. Do you have allergies to medicines, pollens, foods, or stinging insects? c c

32. Have you ever had a head injury or concussion?

c c

6. Have you ever passed out or nearly passed out DURING exercise?

33. Have you been hit in the head and been confused or lost your memory? c c

c c

7. Have you ever passed out or nearly passed out AFTER exercise?

34. Have you ever had a seizure?

c c

8. Have you ever had discomfort, pain, or pressure in your chest during

35. Do you have headaches with exercise?

c c

exercise?

36. Have you ever had numbness, tingling, or weakness in your arms or

c c

9. Does your heart race or skip beats during exercise?

legs after being hit or falling?

c c

10. Has a doctor ever told you that you have (circle all that apply):

37. Have you ever been unable to move your arms or legs after being hit

c c

High blood pressure

A heart murmur

or falling?

High cholesterol

A heart infection

38. When exercising in the heat, do you have severe muscle cramps or

c c

11. Has a doctor ever ordered a test for your heart? (for example, ECG,

become ill?

c c

echocardiogram)

39. Has a doctor told you that your or someone in your family has sickle

c c

12. Has anyone in your family died for no apparent reason?

cell trait or sickle cell disease?

c c

13. Does anyone in your family have a heart problem?

40. Have you had any problems with your eyes or visions?

c c

14. Has any family member or relative died of heart problems or of sudden c c

41. Do you wear glasses or contact lenses?

c c

death before age 50?

42. Do you wear protective eyewear, such as goggles or a face shield?

c c

15. Does anyone in your family have Marfan syndrome?

43. Are you happy with your weight?

c c

16. Have you ever spent the night in a hospital?

44. Are you trying to gain or lose weight?

c c

17. Have you ever had surgery?

45. Have anyone recommended you change your weight or eating habits? c c

c c

18. Have you ever had an injury, like a sprain, muscle or ligament tear or

46. Do you limit or carefully control what you eat?

c c

tendonitis that caused you to miss a practice or game: If yes, circle

47. Do you have any concerns that you would like to discuss with a doctor? c c

affected area below:

FEMALES ONLY

19. Have you had any broken or fractured bones, or dislocated joints?

48. Have you ever had a menstrual period?

c c

If yes, circle below:

49. How old were you when you had your first menstrual period?

______

20. Have you had a bone or joint injury that required x-rays, MRI, CT,

50. How many periods have you had in the last year?

______

c c

surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches?

Explain “Yes” answers here:

If yes, circle below:

__________________________________________________________________

Head

Neck

Shoulder

Upper

Elbow

Forearm

Hand /

Chest

arm

fingers

__________________________________________________________________

Upper

Lower

Hip

Thigh

Knee

Calf/shin

Ankle

Foot /

__________________________________________________________________

back

toes

__________________________________________________________________

21. Have you ever had a stress fracture?

c c

__________________________________________________________________

22. Have you been told that you have or have you had an x-ray for

c c

__________________________________________________________________

atlantoaxial (neck) instability?

__________________________________________________________________

23. Do you regularly use a brace or assistive device?

c c

__________________________________________________________________

24. Has a doctor ever told you that you have asthma or allergies?

c c

__________________________________________________________________

Allergies: ___________________________________________________________________________________________________________

Immunizations: (eg, tetanus/diphtheria;; measles, mumps, rubella;; hepatitis A, B;; influenza;; poliomyelitis, pneumococcal;; meningococcal, varicella)

__________________________________________________________________________________________________________________________

Date of last known tetanus shot: ________________________________________________________________________________________________