Iowa Athletic Pre-Participation Physical Examination Form
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2IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION
ARTICLE VII 36.14(1) PHYSICAL EXAMINATION.
Every year each student (grades 7-12) shall present to the student’s
superintendent a certificate signed by a licensed physician and surgeon, osteopathic physician and surgeon, osteopath, advanced
registered nurse practitioner (ARNP), physician’s assistant or qualified doctor of chiropractic, to the effect that the student has been
examined and may safely engage in athletic competition. This certificate of physical examination is valid for the purposes of this rule
for one (1) calendar year. A grace period, not to exceed thirty (30) days, is allowed for expired certifications of physical examination.
QUESTIONNAIRE FOR ATHLETIC PARTICIPATION
(Please type or neatly print this information)
Student’s Name _________________________________________ Male ___ Female ___ Date of Birth _________ Grade ______
Home Address _______________________________________________________ Phone # ____________________________
Parent’s/Guardian’s Name ______________________________________________ Date ______________________________
Family Physician ______________________________________________________ Phone # ____________________________
HEALTH HISTORY (The following questions should be completed by the student-athlete with the assistance of a
parent or guardian. A parent or guardian is required to sign on the other side of this form after the examination.)
Yes
No
Has this student ever had?
Yes
No
Has this student ever had?
1. _____ _____ Chronic or recurrent illness or injury?
18. _____ _____ Asthma?
2. _____ _____ Any illness lasting more than one (1) week?
19. _____ _____ Epilepsy, or other seizures?
3. _____ _____ Mononucleosis or Rheumatic fever?
20. _____ _____ Diabetes?
4. _____ _____ Hospitalizations (Overnight or longer)?
21. _____ _____ Herpes infection?
5. _____ _____ Surgery, other than tonsillectomy?
22 _____ _____ Marfan Syndrome?
6. _____ _____ Missing organ (eye, kidney, testicle)?
23. _____ _____ Eyeglasses or contact lenses?
7. _____ _____ Allergies to pollen, stinging insects, food, etc.?
8. _____ _____ High blood pressure or high cholesterol?
9. _____ _____ Heart problems (Racing, murmur, skipped beats,
Yes
No
Is there a history of?
infection, etc.?)
24. _____ _____ Injuries requiring medical treatment?
10. _____ _____ Chest pressure or pain with exercise?
25. _____ _____ Neck injury?
11. _____ _____ Dizziness or fainting with exercise?
26. _____ _____ Knee injury or surgery?
12. _____ _____ Excessive shortness of breath with exercise?
27. _____ _____ Other serious joint injuries?
13. _____ _____ Seizures or frequent headaches?
28. _____ _____ Use of protective equipment or braces?
14. _____ _____ Head injury, concussion, unconsciousness?
15. _____ _____ Numbness, tingling or weakness in arms or legs
*****************************************************************
with contact?
29. _____ _____ Has a doctor ever denied or
restricted your participation in
16. _____ _____ Headache, memory loss, or confusion with contact?
17. _____ _____ Severe muscle cramps or become ill when
sports for any reason?
exercising in the heat?
30. _____ _____ Do you have any concerns that
you would like to discuss with
your doctor?
Yes
No
Family History:
31. _____ _____ Does anyone in your family have Marfan syndrome?
32. _____ _____ Has anyone in your family died suddenly for no apparent reason?
33. _____ _____ Has anyone in your family had a heart attack at less than 55 years of age?
Use this space to explain any “YES” answers from above (questions #1-33) or to provide any additional information:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
34. _____ _____ Are you allergic to any prescription or over-the-counter medications? If yes, list:___________________________
35. List all medications you are presently taking (including asthma inhalers & EpiPens) and the condition the medication is for:
A. ________________________________ B. _______________________________ C. _________________________________
36. Year of last known: Tetanus (lockjaw) vaccination: ___________
Meningitis vaccination: ___________
37. What is the most and least you have weighed in the past year? Most ___________________ Least ______________________
38. Are you happy with your current weight? Yes _____ No _____
FOR FEMALES ONLY:
1. How old were you when you had your first menstrual period? ____________________
2. In the past 12 months, what is the longest time you have gone between menstrual periods? ______________________________
Page 1 of 2, Physical Examination Record & Parent’s/Guardian’s Release is on the reverse side
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