Consent/physical Exam Form Page 2
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4The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician
PART II - - MEDICAL HISTORY-Explain “Yes” answers below
This form must be completed and signed, prior to the physical examination, for review by examining physician.
Explain “Yes” answers below with number of the question. Circle questions you don’t know the answers to.
GENERAL MEDICAL HISTORY
Yes
No
MEDICAL QUESTIONS (cont)
Yes
No
1. Has a doctor ever denied or restricted your participation in
29. Do you have groin pain or a painful bulge or hernia in the
Sports for any reason?
groin area?
2. Do you currently have an ongoing medical condition? If so,
30. Have you had mononucleosis (mono) within the last month?
Please identify:
Asthma
Anemia
Diabetes
Infections
Other.
3. Have you ever spent the night in the hospital?
31. Do you have any rashes, pressure sores, or other skin
problems?
4. Have you ever had surgery?
32. Have you ever had a herpes or MRSA skin infection?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
5. Have you ever passed out or nearly passed out DURING or AFTER
33. Are you currently taking any medication on daily basis?
exercise?
6. Have you ever had discomfort, pain, or pressure in your chest
34. Have you ever had a head injury or concussion? If so, date
during exercise?
of last injury:
7. Does your heart race or skip beats during exercise?
35. Have you ever had numbness, tingling, or weakness in your
arms or legs after being hit of falling?
8. Has a doctor ever told you that you have ( check all that apply):
36. Do you have headaches with exercise?
High Blood Pressure
A heart murmur
37. Have you ever been unable to move your arms or legs after
High cholesterol
A heart infection
being hit or falling?
Kawasaki disease
Other
9. Has a doctor ever ordered a test for your heart?
38. When exercising in heat, do you have severe muscle cramps
(for ex: ECG/EKG, echocardiogram)
or become ill?
10. Do you get lightheaded or feel more short of breath than expected
39. Has a doctor told you that you or someone in your family has
during exercise?
sickle cell trait or sickle cell disease?
11. Have you ever had an unexplained seizure?
40. Have you had any other blood disorders?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes
No
41. Have you had any problem with your eyes or vision?
12. Has any family member or relative died of heart problems or had
42. Do you wear glasses or contact lenses?
an unexpected sudden death before age 50 (including drowning,
43. Do you wear protective eyewear, such as goggles or face
unexplained car accident or sudden infant death syndrome)?
shield?
44. Do you worry about you weight?
13. Does anyone in your family have a heart problem?
45. Are you trying to or has any professional recommended that
you try to gain or lose weight?
14. Does anyone in your family have a pacemaker or implanted
46. Do you limit or carefully control what you eat?
defibrillator?
15. Does anyone in your family have Marfan syndrome,
47. Do you have any concerns that you would like to discuss
cardiomyopathy or Long Q-T?
with a doctor?
16. Has anyone in your family had unexplained fainting, unexplained
48. What is the date of your last Tetanus immunizations?
Seizures, or near drowning?
Date:_____________________________
BONE AND JOINT QUESTIONS
Yes
No
49. Do you have an allergy to medicine, food, or stinging
insects?
17. Have you ever had an injury, like a sprain, muscle or ligament
FEMALES ONLY
tear, or tendonitis that caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints?
50. Have you ever had a menstrual period?
19. Have you had a bone or joint injury that required x-rays, MRI, CT,
51. Age when you had your first menstrual period? _______
Surgery, injections, rehabilitation, physical therapy, a brace, a cast
or crutches?
20. Have you ever had an x-ray or your neck for atlanto-axial
52. How many periods have you had in the last 12 months?
Instability? OR have you ever been told that you have that
disorder or any neck/spine problem?
21. Have you ever had a stress fracture of a bone?
22. Do you regularly use a brace or assistive device?
EXPLAIN “YES” ANSWERS BELOW:
23. Do you currently have a bone, muscle, or joint injury that bothers
#___>________________________________________________________
you?
#___>________________________________________________________
24. Do any of your joints become painful, swollen, feel warm, or look
red?
#___>________________________________________________________
25. Do you have a history of juvenile arthritis or connective tissue
disease?
#___>________________________________________________________
MEDICAL QUESTIONS
Yes
No
26. Do you cough, wheeze, or have difficulty breathing during or after
#___>________________________________________________________
exercise?
27. Do you have asthma or use asthma medicine (inhaler, nebulizer)?
*List medications and nutritional supplements you are currently taking here:
28. Were you born without or are you missing a kidney, an eye, a
testicle, spleen or any other organ?
Parent/Guardian Signature: _____________________Date:________ Athlete’s Signature: _______________
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