Athletic Pre-Participation Physical Examination Form - New Jersey Department Of Education Page 2
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44.
Have you had or do you currently have any of the following eye, ear, nose, mouth or throat conditions
since your last physical:
a. Vision problems?
Y / N / Don’t Know
1. Wear contacts, eyeglasses or protective eye wear? (Circle which type.)
Y / N / Don’t Know
b. Hearing loss or problems?
Y / N / Don’t Know
1. Wear hearing aides or implants?
Y / N / Don’t Know
c. Nasal fractures or frequent nose bleeds?
Y / N / Don’t Know
d. Wear braces, retainer or protective mouth gear?
Y / N / Don’t Know
e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)?
Y / N / Don’t Know
5. Have you had or do you currently have any of the following neuromuscular/orthopedic conditions since your last physical:
a.
A burner, stinger or pinched nerve?
Y / N / Don’t Know
b.
A sprain?
Y / N / Don’t Know
c.
A strain?
Y / N / Don’t Know
d.
Swelling or pain in muscles, tendons, bones or joints?
Y / N / Don’t Know
e.
A dislocated joint(s)?
Y / N / Don’t Know
f.
Upper or lower back pain?
Y / N / Don’t Know
g.
Fracture(s) or stress fracture(s)?
Y / N / Don’t Know
h.
Do you wear any protective braces or equipment for any prior injury?
Y / N / Don’t Know
6. Have you had or do you currently have any of the following general or exercise related conditions since your last physical:
a. Difficulty breathing? During Exercise? (Circle one.)
1. After running one mile
Y / N / Don’t Know
2. Coughing, wheezing or shortness of breathe in weather changes?
Y / N / Don’t Know
3. Exercise-induced asthma
Y / N / Don’t Know
i. Controlled with medication? (List below.)
Y / N / Don’t Know
ii. Experience dizziness, passing out or fainting?
Y / N / Don’t Know
b. Viral infections (e.g. mono, hepatitis)?
Y / N / Don’t Know
c. Become tired more quickly than your friends?
Y / N / Don’t Know
d. Any of the following skin conditions:
1. Acne, contact dermatitis, ringworm, warts, herpes?
Y / N / Don’t Know
2. Sun sensitivity?
Y / N / Don’t Know
e. Weight gain/loss (greater than or less than 10 pounds)?
Y / N / Don’t Know
1. Do you want to weigh more or less than you do now?
Y / N / Don’t Know
f. Ever had feelings of depression?
Y / N / Don’t Know
g. Heat-related problems (dehydration, dizziness, fatigue, headache)?
Y / N / Don’t Know
1. Heat exhaustion (cool, clammy, damp skin)?
Y / N / Don’t Know
2. Heat stroke (hot, red, dry skin)?
Y / N / Don’t Know
7. Females only:
Age of onset of menstruation:__________________________________________________________________________________
Date of last menstruation:_____________________________________________________________________________________
Most number of days between menstruation cycle(s):_______________________________________________________________
Explain all (yes) answers here (include relevant dates)
:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
___________________________________________________________________________________________________
I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature.
Parent/Guardian Signature:_________________________________
Date:_________________
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