Middle Schools Pre-Participation Physical Evaluation Form
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1
22015/2016
VALID FOR SCHOOL YEAR
STUDENT ID: _____________________
:
Pre-participation Physical Evaluation. Junior High/Middle Schools
Student History
Home Phone
–
___________________E-mail ________________________________Date of Exam ______________
Name ____________________________________________ Sex _____ Age _____ Grade _____ Date of Birth ____________
LAST NAME
FIRST NAME
Sport(s) Interested in Participating __________________________________________________________________________
Home Address ________________________________________________ City __________________ Zip Code ___________
Personal physician ______________________________________________________________________________________
In case of emergency, contact
Name ______________________________________ Relationship ______________ Phone (H) _______________ (W) _______________
Explain “YES” answers below:
Circle questions you don’t know the answers to.
YES
NO
YES
NO
1.
Have you had a medical illness or Injury since your last
10.
Do you use any special protective or corrective
check up or sports physical?
equipment or devices that aren’t usually used
Do you have an ongoing or chronic illness?
for your sport or position (for example, knee
2.
Have you ever been hospitalized overnight?
brace, special neck roll, foot orthotics, retainer
Have you ever had surgery?
on your teeth, hearing aid)?
3.
Are you currently taking any prescription or
11.
Have you had any problems with your eyes or
nonprescription (over-the-counter) medications or pills
vision?
or using an inhaler?
Do you wear glasses, contacts, or protective
Have you ever taken any supplements or vitamins to
eyewear?
help you gain or lose weight or improve your
12.
Have you ever had a sprain, strain, or swelling
performance?
after injury?
4.
Do you have any allergies (for example, to pollen,
Have you broken or fractured any bones or
medicine, food, or stinging insects)?
dislocated any joints?
Have you ever had a rash or hives develop during or
Have you had any other problems with pain or
after exercise?
swelling in muscles, tendons, bones, or joints?
5.
Have you ever passed out during or after exercise?
If yes, check appropriate box and explain below.
Have you ever been dizzy during or after exercise?
Upper arm
Head
Elbow
Hip
Have you ever had chest pain during or after exercise?
Finger
Neck
Forearm
Thigh
Do you get tired more quickly than your friends do
Ankle
Back
Wrist
Knee
during exercise?
Foot
Chest
Hand
Shin/calf
Have you ever had racing of your heart or skipped
Shoulder
heartbeats?
Have you had high blood pressure or high cholesterol?
13.
Do you want to weigh more or less than you do
Have you ever been told you have a heart murmur?
now?
Has any family member or relative died of heart
Do you lose weight regularly to meet weight
problems or of sudden death before age 50?
requirements for your sport?
Have you had a severe viral infection (for example,
14.
Do you feel stressed out?
myocarditis or mononucleosis) within the last month?
15.
Record the dates of your most recent
Has a physician ever denied or restricted your
immunizations (shots) for:
participation in sports for any heart problems?
Tetanus _________________
Measles
6.
Do you have any current skin problems (for example,
Hepatitis B _______________
Chickenpox
itching, rashes, acne, warts, fungus, or blisters)?
FEMALES ONLY
7.
Have you ever had a head Injury or concussion?
16.
When was your first menstrual period?
Have you ever been knocked out, become
When was your most recent menstrual period?
unconscious, or lost your memory?
How much time do you usually have from the
Have you ever had a seizure?
start of one period to the start of another?
Do you have frequent or sever headaches?
How many periods have you had in the last
Have you ever had numbness or tingling in your arms,
year?
hands, legs, or feet?
What was the longest time between periods in
Have you ever had a stinger, burner, or pinched nerve?
the last year?
8.
Have you ever become ill from exercising in the heat?
Explain “YES” answers here:
9.
Do you cough, wheeze, or have trouble breathing
during or after activity?
Do you have asthma?
Do you have seasonal allergies that require medical
treatment?
I hereby state that, 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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