2005 Pre-Participation Physical Evaluation Form printable pdf download

KANSAS STATE HIGH SCHOOL ACTIVITIES ASSOCIATION

PO Box 495, 601 SW Commerce Place; Topeka, KS 66601-0495; (785) 273-5329

PPE

HISTORY

PRE-PARTICIPATION PHYSICAL EVALUATION

TO BE COMPLETED ANNUALLY BY EVERY PARTICIPANT AND PARENT OR GUARDIAN

Name

Sex

Age

Date of birth

Grade

School

Sport(s)

Address

Phone (

)

Personal physician

In case of emergency, contact:

Name

Relationship

Phone (H)

(W)

STUDENT/PARENT/GUARDIAN - answer questions below PRIOR TO EXAMINATION by physician.

Explain “YES” answers in space below. Circle the number of the questions you do not know.

YES NO

Have you had a medical illness or injury since your last

10.

Do you use any special protective or corrective equipment or

check up or sports physical?

devices that aren’t usually used for your sport or position (for

example, knee brace, special neck roll, foot orthotics, retainer

Do you have an ongoing or chronic illness?

on your teeth, hearing aid)?

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?

Are you currently taking any prescription or non-prescription

12.

Have you ever had a sprain, strain, fracture or dislocation

(over-the-counter) medications or pills or using an

of a muscle, tendon, bone or joint?

inhaler?

If yes, check appropriate box and explain below.

Have you ever taken any supplements or vitamins to help

you gain or lose weight or improve your performance?

Head

Elbow

Hip

Do you have any allergies (for example, to pollen, medicine,

Neck

Forearm

Thigh

food, or stinging insects)? Have you ever had a rash or hives

Back

Wrist

Knee

develop during or after exercise?

Chest

Hand

Shin/calf

Have you ever passed out during or after exercise?

Shoulder

Finger

Ankle

Have you ever been dizzy during or after exercise?

Upper arm

Foot

Have you ever had chest pain during or after exercise?

13.

Do you want to weigh more or less than you do now?

Do you get tired more quickly than your friends do during

Do you lose weight regularly to meet weight requirements

exercise?

for your sport?

Have you ever had racing of your heart or skipped heartbeats?

14.

Has a doctor told you or a family member that you are at

Have you had high blood pressure or high cholesterol?

risk for blood disorders? Ex: Sickle Cell, etc…

Have you ever been told you have a heart murmur?

15.

Were you born without or are you missing a kidney, testicle

or any other organs?

Has any family member or relative died of heart problems

Do you feel that you have fatigue or increased shortness of

or of sudden death before age 50?

breath with activity?

Have you had a severe viral infection (for example, myocarditis

17.

Do you have any concerns that you would like to discuss

or mononucleosis) within the last month?

with the doctor?

Has a physician ever denied or restricted your participation

in sports for any heart problems?

FEMALES ONLY

Do you have any current skin problems (for example itching,

rashes, acne, warts, fungus, or blisters)?

18.

Have you begun menstruation?

Have you ever had a head injury or concussion?

If yes, are you ever experiencing any problem

When? ________________________ How many? ________

(i.e., irregularity, pain, etc.)?

Have you ever been knocked out, become unconscious, or

lost your memory?

IDENTIFY “YES” ANSWERS (by number)

Have you ever had a seizure?

Have you ever had numbness or tingling in your arms, hands,

legs, or feet?

Have you ever had a stinger, burner, or pinched nerve?

Have you ever become ill from exercising in the heat?

Do you cough, wheeze, or have trouble breathing during or

after activity?

Do you have asthma?

Do you use an inhaler before excercise?

Do you have seasonal allergies requiring medical treatment?

Rev. 2/05

2005 Pre-Participation Physical Evaluation Form

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