Ihsa - Preparticipation Examination Form
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1
2Preparticipation Examination
Yes
No
If yes, please
explain (what,
where, when)
To be completed by athlete or parent prior to examination.
Have you had high blood pressure or
high cholesterol?
__________ __________
______________
Name ____________________________________________________ Sport/Position ________________
Have you ever been told you have a heart murmur? __________ __________
______________
Last
First
Middle
Has any family member or relative died of heart
problems or of sudden death before age 50?
__________ __________
______________
Social Security Number __________________________________ School Year __________________
Have you had a severe viral infection (for example
Address __________________________________________________________________________________
myocarditis or mononucleosis) within the last month?_________ __________
______________
City/State ________________________________________________ Phone No. ____________________
Has a physician ever denied or restricted your
Birthdate ___________________ Age________ Class ________ Student ID No. ________________
participation in sports for any heart problems?
__________ __________
______________
Parent’s Name____________________________________________________________________________
Has anyone in your family had a heart attack
Address __________________________________________________________________________________
before the age of 50?
__________ __________
______________
Phone No. _______________________
16.
Head and Nerve
Person to contact in case of emergency___________________________________________________
Have you ever had a head injury or concussion?
__________ __________
______________
Have you ever been knocked out, become
Phone No. _______________________
unconscious, or lost your memory?
__________ __________
______________
Family Doctor ____________________________ City/State ____________________________________
Have you ever had a seizure?
__________ __________
______________
Phone No. _______________________
Do you have frequent or severe headaches?
__________ __________
Have you ever had numbness or tingling in
Past Medical History
Yes
No
If yes, please
your arms, hands, legs or feet?
__________ __________
______________
explain (what,
Have you ever had a stinger, burner or
where, when)
pinched nerve?
__________ __________
______________
1.
Presently taking medication
17.
Last tetnus shot?
Date_________________
(including birth control pills)?
__________ __________
______________
18.
Last eye exam?
Date_________________
2.
Have you been diagnosed with asthma?
__________ __________
______________
19.
Last menstrual period (if women)
Date_________________
3.
Have you been prescribed by a physician to
use any asthma medication?
__________ __________
______________
Personal Habits
Yes
No
4.
Do you have a current consent form to
1.
Smoking/smokeless tobacco
__________ __________
self-administer the asthma medication on
2.
Alcohol/non-medical drugs: marijuana, cocaine, etc __________ __________
file with your school?
__________ __________
______________
3.
Steroids
__________ __________
5.
Allergic to medicine, foods, bee stings?
__________ __________
______________
4.
Eating Disorders – weight loss or gain?
__________ __________
6.
Wears any appliances—glasses, contact lenses?
__________ __________
______________
7.
History of braces, chipped teeth, bridges?
__________ __________
______________
Review of systems (Please check if you have any problems with any of the following areas of your
8.
Has ongoing medical problem?
__________ __________
______________
body)
9.
Had serious or significant illness in past?
__________ __________
______________
___________Skin
___________Lungs
___________Shoulders, Arms,
10.
Any past surgical operations, accidents,
non-sports or related injuries?
__________ __________
______________
___________Head
___________Heart
Hands
11.
Any past injuries directly related to sports?
__________ __________
______________
___________Eyes
___________Abdomen
___________Hips, Legs, Feet
12.
Any hospitalization not explained above?
__________ __________
______________
___________Ears
___________Back
___________Muscles—Strength,
13.
Any known deformities (such as curvature of
___________Nose
___________Urination,
Feeling
back, heart problems, one kidney, blindness in
___________Mouth/Throat
Bowel Control
___________Mental, Emotional
one eye, one testicle, etc.)?
__________ __________
______________
___________Nutrition,
___________Genital (including
___________Fatigue
14.
Any serious family illness (such as diabetes,
Weight Control
menstrual for women) ___________Other: What?
bleeding disorders, etc.)?
__________ __________
______________
___________Neck
_____________________________
15.
Heart
Have you ever passed out during or after exercise? __________ __________
______________
I certify that the above information is correct to the best of my knowledge.
Have you ever been dizzy during or after exercise?
__________ __________
______________
Have you ever had chest pain during or
after exercise?
__________ __________
______________
Student Signature _____________________________________________________________________________
Do you get tired more quickly than your
friends do during exercise?
__________ __________
______________
Parent/Guardian Signature_____________________________________________________________________
Have you ever had racing of your heart or
skipped heartbeats?
__________ __________
______________
Both Student And Parent/Guardian Signatures Are Mandatory
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