North Carolina High School Athletic Association Sport Preparticipation Examination Form printable pdf download

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION

SPORT PREPARTICIPATION EXAMINATION FORM

Patient’s Name: ____________________________________________________

Age: ______

Sex: _____

This is a screening examination for participation in sports. This does not substitute for a comprehensive

examination with your child’s regular physician where important preventive health information can be covered.

Athlete’s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your

knowledge.

Parent’s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or

don’t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk during

sports activity.

Physician’s Directions: We recommend carefully reviewing these questions and clarifying any positive or Don’t Know answers.

Explain “Yes” answers below

Yes

Don’t

know

1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, etc.]?



List:

2. Is the athlete presently taking any medications or pills?



3. Does the athlete have any allergies (medicine, bees or other stinging insects, latex)?



4. Does the athlete have the sickle cell trait?

5. Has the athlete ever had a head injury, been knocked out, or had a concussion?



6. Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities?



7. Has the athlete ever passed out or nearly passed out DURING exercise, emotion or startle?



8. Has the athlete ever fainted or passed out AFTER exercise?



9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)?

10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise?



11. Has the athlete ever been diagnosed with exercise-induced asthma ?



12. Has a doctor ever told the athlete that they have high blood pressure?



13. Has a doctor ever told the athlete that they have a heart infection?



14. Has a doctor ever ordered an EKG or other test for the athlete’s heart, or has the athlete ever been told they have a

murmur?



15. Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of their

heart “racing” or “skipping beats”?

16. Has the athlete ever had a seizure or been diagnosed with an unexplained seizure problem?

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17. Has the athlete ever had a stinger, burner or pinched nerve?



18. Has the athlete ever had any problems with their eyes or vision?



19. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of



any bones or joints?

 Head

 Shoulder

 Thigh

 Neck

 Elbow

 Knee

 Chest

Hip

 Forearm  Shin/calf

 Back

 Wrist

 Ankle

 Hand

 Foot



20. Has the athlete ever had an eating disorder, or do you have any concerns about your eating habits or weight?

21. Has the athlete ever been hospitalized or had surgery?

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22. Has the athlete had a medical problem or injury since their last evaluation?



FAMILY HISTORY

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23. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death



syndrome [SIDS], car accident, drowning)?

24. Has any family member had unexplained heart attacks, fainting or seizures?



25. Does the athlete have a father, mother or brother with sickle cell disease?

_________________________________________________________________

Elaborate on any positive (yes) answers:

________________________________________________________________________________________________

By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is

correct to the best of my knowledge. Furthermore, as parent or legal custodian, I give consent for this examination and give

permission for my child to participate in sports.

Signature of parent/legal custodian: ________________________________________ Date: __________________

Signature of Athlete: _______________________________Date: __________________Phone #: ________________

North Carolina High School Athletic Association Sport Preparticipation Examination Form

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