History Form - Preparticipation Physical Evaluation

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P
P
E
REPARTICIPATION
HYSICAL
VALUATION
HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.)
Name _________________________________________________________________ Sex __F __M Age ___ Date of Birth _____________
Grade ____
School __________________________________ Sport(s) __________________________________________ Date of Exam ________________
Address ____________________________________________________________________________________ Phone ______________________
EMERGENCY CONTACT NAME ______________________________________________ Relationship __________________ Phone ______________________
Medicines and Allergies: Please list all of 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
GENERAL QUESTIONS
Yes
No
MEDICAL QUESTIONS
Yes
No
1. Has a doctor ever denied or restricted your participation in sports for
26. Do you cough, wheeze, or have difficulty breathing during or after
any reason?
exercise?
2. Do you have any ongoing medical conditions? If so, please identify
27. Have you ever used an inhaler or taken asthma medicine?
below  Asthma
 Anemia
 Diabetes
 Infections
28. Is there anyone in your family who has asthma?
Other ___________________________________________________
29. Were you born without or are you missing a kidney, an eye, a testicle
3. Have you ever spent the night in the hospital?
(males), your spleen, or any other organ?
4. Have you ever had surgery?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or AFTER
32. Do you have any rashes, pressure sores, or other skin problems?
exercise?
33. Have you had a herpes or MRSA skin infection?
6. Have you ever had discomfort, pain, tightness, or pressure in your
chest during exercise?
34. Have you ever had a head injury or concussion?
7. Does your heart ever race or skip beats (irregular beats) during
35. Have you ever had a hit or blow to the head that caused confusion,
exercise?
prolonged headache, or memory problems?
8. Has a doctor ever told you that you have any heart problems? If so,
36. Do you have a history of seizure disorder?
check all that apply:
37. Do you have headaches with exercise?
 High blood pressure
 A heart murmur
38. Have you ever had numbness, tingling, or weakness in your arms or
 High cholesterol
 A heart infection
legs after being hit or falling?
 Kawasaki disease Other ______________________
39. Have you ever been unable to move your arms or legs after being hit or
9. Has a doctor ever ordered a test for your heart? (For example,
falling?
ECG/EKG, echocardiogram)
40. Have you ever become ill while exercising in the heat?
10. Do you get lightheaded or feel more short of breath than expected
41. Do you get frequent muscle cramps when exercising?
during exercise?
42. Do you or someone in your family have sickle cell trait or disease?
11. Have you ever had an unexplained seizure?
43. Have you had any problems with your eyes or vision?
12. Do you get more tired or short of breath more quickly than your
friends during exercise?
44. Have you had any eye injuries?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes
No
45. Doe you wear glasses or contact lenses?
13. Has any family member or relative died of heart problems or had an
46. Do you wear protective eyewear, such as goggles or a face shield?
unexpected or unexplained sudden death before age 50 (including
47. Do you worry about your weight?
drowning, unexplained car accident, or sudden infant death
syndrome)?
48. Are you trying to or has anyone recommended that you gain or lose
weight?
14. Does anyone in your family have hypertrophic cardiomyopathy,
Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy,
49. Are you on a special diet or do you avoid certain types of foods?
long QT syndrome, short QT syndrome, Brugada syndrome, or
50. Have you ever had an eating disorder?
catecholaminergic polymorphic ventricular tachycardia?
51. Do you have any concerns that you would like to discuss with a
15. Does anyone in your family have a heart problem, pacemaker, or
doctor?
implanted defibrillator?
FEMALES ONLY
Yes
No
16. Has anyone in your family had unexplained fainting, unexplained
seizures, or near drowning?
52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS
Yes
No
53. How old were you when you had your first menstrual period?
17. Have you ever had an injury to a bone, muscle, ligament, or tendon
54. How many periods have you had in the last 12 months?
that caused you to miss a practice or a game?
Explain “yes” answers here
18. Have you ever had any broken or fractured bones or dislocated joints?
________________________________________________________________________________
19. Have you ever had an injury that required x-rays, MRI, CT scan,
________________________________________________________________________________
injections, therapy, a brace, a cast, or crutches?
________________________________________________________________________________
________________________________________________________________________________
20. Have you ever had a stress fracture?
________________________________________________________________________________
21. Have you ever been told that you have or have you had an x-ray for
________________________________________________________________________________
neck instability or 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?
________________________________________________________________________________
***PARENTS/GUARDIANS: Please be sure that you and your child have signed and dated ALL
24. Do any of your joints become painful, swollen, feel warm, or look red?
highlighted locations below.**
25. Do you have any history of juvenile arthritis or connective tissue
disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and accurate.
Signature of athlete ______________________________________
Signature of parent/guardian_________________________________
Date ______________________
Parent’s Permission & Acknowledgement of Risk for Son or Daughter to Participate in Athletics
As the parent or legal guardian of the above named student-athlete, I give my permission for his/her participation in athletic events and the physical evaluation for that participation. I understand that this is simply a
screening evaluation and not a substitute for regular health care. I also grant permission for treatment deemed necessary for a condition arising during participation of these events, including medical or surgical treatment
that is recommended by a medical doctor. I grant permission to nurses, athletic trainers and coaches as well as physicians or those under their direction who are part of athletic injury prevention and treatment, to have
access to necessary medical information. I know that the risk of injury to my child/ward comes with participation in sports and during travel to and from play and practice. I have had the opportunity to understand the risk
of injury during participation in sports through meetings, written information or by some other means. My signature indicates that to the best of my knowledge, my answers to the above questions are complete and correct.
I understand that the data acquired during these evaluations may be used for research purposes.
Signature of athlete_________________________________________________________________________________
Date_________________________
Signature ofparent/guardian_________________________________________________________________________
Date _________________________

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