Lausd - Preparticipation Physical Evaluation Form

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Los Angeles Unified School District
Preparticipation Physical Evaluation
Appendix A
Date of Exam: ____________________
Page 1 of 2
Student's Name: ____________________________________________________ Sex: _____ Age: _____ Date of Birth: __________________
Grade: _____ School: ___________________________________________________ Sport(s): ______________________________________
Address: __________________________________________________________________________________ Phone: ___________________
Personal Physician/Provider: ___________________________________________________________________________________________
In case of emergency, contact:
Name: ________________________________________________ Relationship: _______________________
Phone (H): ___________________ (W): _____________________ (Cell): ________________________ (Cell): ________________________
Medicines and Allergies: Please list all the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies?
Yes
No If yes, please identify specific allergy below.
Medicines
Pollens
Food
Stinging insects
This section is to be carefully completed by the student and his/ her parent(s) or legal guardian(s) before participation in interscholastic athletics. Explain Yes answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS
Yes No MEDICAL QUESTIONS
Ye No
s
1. Has a doctor ever denied or restricted your participation in sports for any reason?
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
2. Do you have any ongoing medical conditions? If so, please identify below:
Asthma
27. Have you ever used an inhaler or taken asthma medicine?
Anemia
Diabetes
Infections Other:_____________________
3. Have you ever spent the night in a hospital?
28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, an eye, a testicle (males),
4. Have you ever had surgery?
your spleen, or any other organ?
HEART HEALTH QUESTIONS ABOUT YOU
Yes No 30. Do you have groin pain or a painful bulge or hernia in the groin area?
5. Have you ever passed out or nearly passed out DURING or AFTER exercise?
31. Have you had infectious mononucleosis (mono) within the last month?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during
32. Do you have any rashes, pressure sores, or other skin problems?
exercise?
7. Does your heart ever race or skip beats (irregular beats) during exercise?
33. Have you had a herpes or MRSA skin infection?
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
34. Have you ever had a head injury or concussion?
35. Have you ever had a hit or blow to the head that caused confusion, prolonged
Kawasaki disease
A Heart Infection
headache, or memory problems?
High Blood Pressure
A Heart Murmur
36. Do you have a history of seizure disorder?
High Cholesterol
Other_____________________
37. Do you have headaches with exercise?
9. Has a doctor ever ordered a test for your heart (for example, ECG/EKG,
38. Have you ever had numbness, tingling, or weakness in your arms or legs after
echocardiogram)?
being hit or falling?
10. Do you get lightheaded or feel more short of breath than expected during exercise?
39. Have you ever been unable to move your arms or legs after being hit or falling?
40. Have you ever become ill while exercising in the heat?
11. Have you ever had an unexplained seizure?
12. Do you get more tired or short of breath more quickly than your friends during exercise?
41. Do you get frequent muscle cramps when exercising?
HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes No 42. Do you or someone in your family have sickle cell trait or disease?
13. Has any family member or relative died of heart problems or had an unexpected
43. Have you had any problems with your eyes or vision?
or unexplained sudden death before age 50 (including drowning, unexplained
44. Have you had any eye injuries?
car accident, or sudden infant death syndrome?)
45. Do you wear glasses or contact lenses?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome,
46. Do you wear protective eyewear, such as goggles or a face shield?
arrythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome
47. Do you worry about your weight?
Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
48. Are you trying to or has anyone recommended that you gain or lose weight?
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
49. Are you on a special diet or do you avoid certain types of food?
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near
50. Have you ever had an eating disorder?
drowning?
BONE AND JOINT QUESTIONS
Yes No 51. Do you have any concerns that you would like to discuss with a doctor?
17. Have you ever had an injury, like a sprain, muscle, or ligament tear, or tendinitis that
FEMALES ONLY
caused you to miss a practice or game?
18. Have you had any broken or fractured bones or dislocated joints?
52. Have you ever had a menstrual period?
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a
53. How old were you when you had your first menstrual period?
brace, a cast, or crutches?
20. Have you ever had a stress fracture?
54. How many periods have you had in the last 12 months?
21. Have you been told that you have or have you had an x-ray for neck instability or
Explain "yes" answers here:
atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics or other assistive device?
23. Do you 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 any history of juvenile arthritis or connective tissue disease?
I hereby state, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete_________________________ Signature of parent/guardian_________________________________ Date___________________

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