Athletic Pre-Participation Physical Examination Form - New Jersey Department Of Education

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New Jersey Department of Education
ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM
Part A: HEALTH HISTORY QUESTIONNAIRE
(To be completed by the parent and student)
(Pursuant to N.J.A.C. 6A:16 Programs to Support Student Development)
Date of Last Physical: __________________________
Today’s Date:_____________________
Student’s Name: __________________________________
Sex: M F (circle one)
Age: ______
Date of Birth: ____________________________ Sport: ______________________
Home Phone: _____________________________
Grade: __________ School: _____________________________
District: _________________________
Physician: _______________________________
Phone: __________________________
Fax: _____________________
E
C
I
MERGENCY
ONTACT
NFORMATION
Name: ____________________________
Relationship to student: _____________________
______________
Phone (work): _____________________
Phone (home):______________________________
Phone (cell):
Directions: Please answer the following questions about the student’s medical history. Explain all “yes” responses at the bottom of the page. Please
respond to all questions.
1. Have you had or do you currently have:
a. A sports physical within the past 365 days?
Y / N / Don’t Know
b. An injury or illness since your last exam?
Y / N / Don’t Know
c. A chronic or ongoing illness (such as diabetes or asthma)?
Y / N / Don’t Know
1. Use an inhaler or other prescription medicine to control asthma?
Y / N / Don’t Know
d. Any prescribed or over the counter medications that you take on a regular basis?
Y / N / Don’t Know
e. Surgery, hospitalization or any emergency room visit(s)?
Y / N / Don’t Know
f. Any allergies to medications?
Y / N / Don’t Know
g. Any allergies to bee stings, pollen, latex or foods?
Y / N / Don’t Know
1. Type of reaction: Rash? Hives? Other skin condition? (Circle all that apply.)
Y / N / Don’t Know
2. Take any medication/Epipen taken for allergy symptoms? (List below.)
Y / N / Don’t Know
h. Any anemias or blood disorders?
Y / N / Don’t Know
2. Have you had or do you currently have any of the following head-related conditions since your last physical:
a. Concussion requiring a physician’s evaluation?
Y / N / Don’t Know
1. How often and when? (Answer below.)
b. Memory loss or been knocked out?
Y / N / Don’t Know
c. A seizure?
Y / N / Don’t Know
d. Frequent or severe headaches?
Y / N / Don’t Know
3. Have you had or do you curently have any of the following heart-related conditions since your last physical:
a. Chest pain?
Y / N / Don’t Know
b. Heart murmur?
Y / N / Don’t Know
c. High blood pressure or elevated cholesterol level?
Y / N / Don’t Know
d. Restriction from sports for heart problems?
Y / N / Don’t Know
e. Any family member or relative:
1. Die of a heart problem before age 35?
Y / N / Don’t Know
2. Die of a heart problem before age 50?
Y / N / Don’t Know
3. Die with no known reason?
Y / N / Don’t Know
4 Die while exercising? During or after? (Circle one.)
Y / N / Don’t Know
5. With Marfan’s Syndrome?
Y / N / Don’t Know
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