State Of Illinois Certificate printable pdf download

Preparticipation Examination

To be completed by athlete or parent prior to examination.

If yes, please

explain (what,

Name

Sport/Position

Yes

where, when)

Last

First

Middle

Have you had high blood pressure or

high cholesterol?

Social Security Number

School Year

Have you ever been told you have a heart murmur?

Address

Has any family member or relative dies of heart

problems or of sudden death before age 50?

City/State

Phone No.

Have you had a severe viral infection (for example

myocarditis or mononucleosis) within the last month?

Birthdate

Age

Class

Student ID No.

Has a physician ever denied or restricted your

participation in sports for any heart problems?

Parent’s Name

Has anyone in your family had a heart attack before

the age of 50?

Address

16.

Head and Nerve

Phone No.

Have you ever had a head injury or concision?

Have you ever been knocked out, become

Person to contact in case of emergency

unconscious, or lost your memory?

Have you ever had a seizure?

Phone No.

Do you have frequent or severe headaches?

Family Doctor

City/State

Have you ever had numbness or tingling in your arms,

hands, legs or feet?

Phone No.

Have you ever had a stinger, burner, or pinched

nerve?

Past Medical History

Yes

If yes, please

17.

Last tetanus shot?

Date

explain (what,

18.

Last eye exam?

Date

where, when)

19.

Last Menstrual period (if women)

Date

Presently taking medication

(including birth control pills)?

Yes

Have you been diagnosed with asthma?

Personal Habits

Have you been prescribed by a physician to use any

Smoking/smokeless tobacco

asthma medication?

Alcohol/non-medical drugs: marijuana, cocaine, etc.

Do you have a current consent form to self-administer

Steroids

the asthma medication on file with your school?

Easting Disorders – weight loss or gain?

Allergic to medicine, foods, bee stings?

Wears any appliances – glasses, contact lenses?

History of braces, chipped teeth, bridges?

Review of systems (Please check if you have any problems with any of the following areas of your

Has ongoing medical problem?

body)

Had serious or significant illness in past?

Shoulders, Arms,

Skin

Lungs

Hands

10.

Any past surgical operations, accidents, non-sports or

related injuries?

Head

Heart

Hips, Legs, Feet

11.

Any past injuries directly related to sports?

Muscle–Strength,

Eyes

Abdomen

Feeling

12.

Any hospitalization no explained above?

13.

Any known deformities (such as curvature of back,

Nose

Back

Mental, Emotional

heart problems, one kidney, blindness in one eye, one

Urination,

testicle, etc.)?

Mouth/Throat

Bowel Control

Fatigue

14.

Any serious family illness (such as diabetes, bleeding

Nutrition,

Genital (including

disorders, etc.)?

Weight Control

menstrual for women)

Other: What?

15.

Heart

Neck

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 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

State Of Illinois Certificate

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