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Archdiocese of Miam i

Departm ent of Schools

Athletic Pre-participation Physical Evaluation (Page 1 of 2)

This completed form must be kept on file by the school

Part 1. Student Information (to be completed by the parent).

Student Name:____________________________________________________________ Sex:_______ Age________ Date of Birth_______/_______/_______

School:_____________________________________ Grade in School_______ Sport(s) expected to play___________________________________________

Home Address:______________________________________________________________________ Home Phone (

)____________________________

Name of Parent/Guardian:__________________________________________________________________________________________________________

Person to Contact in Case of Emergency:______________________________________________________________________________________________

Relationship to Student:____________________________Home Phone: (

)_______________________ Work Phone: (

)_______________________

Personal/Family Physician:_________________________ City/State:___________________________________ Office Phone: (

)___________________

Part 2. Medical History (to be completed by parent). Explain “yes” answers below. Circle questions for which you do not know the answer

Yes

N o

Yes

N o

Has child had a medical illness or injury since the last check up or

_____ _____

26. Has child ever become ill from exercising in the heat?

_____

sports physical?

27. Does child cough, wheeze or have trouble breathing during or after

_____ _____

Does child have an ongoing chronic illness?

_____ _____

activity?

Has child ever been hospitalized overnight?

_____ _____

28. Does child have asthma?

_____ _____

Has child ever had surgery?

_____ _____

29. Does child have seasonal allergies that require medical treatment?

_____ _____

Is child currently taking any prescription or nonprescription (over the

_____ _____

30. Does child have any special protective or corrective equipment or

_____ _____

counter) medications or pill or using an inhaler?

devices that aren’t usually used for your sport or position (for example,

knee brace, special neck roll, foot orthotics, retainer on your teeth,

Has child ever taken any supplements or vitamins to help gain or lose

_____ _____

hearing aid)?

weight or improve performance?

31. Has child had any problems with his/her eyes or vision?

_____ _____

Does child have any allergies (for example to pollen, medicine, food or

_____ _____

stinging insects)?

32. Does child wear glasses, contacts, or protective eye wear?

_____ _____

Has child ever had rash or hives develop during or after exercise?

_____ _____

33. Has child ever had a sprain, strain, or swelling after injury?

_____ _____

Has child ever passed out during or after exercise?

_____ _____

34. Has child broken or fractured any bones or dislocated any joints?

_____ _____

10. Has child ever been dizzy during or after exercise?

_____ _____

35. Has child had any other problems with pain or swelling in muscles,

_____ _____

tendons, bones, or joints?

11. Has child ever had chest pain during or after exercise?

_____ _____

If yes, check appropriate blank and explain below:

12. Does child get tired more quickly than friends during exercise?

_____ _____

___ Head

___ Elbow

___ Hip

13. Has child ever had racing of the heart of skipped heartbeats?

_____ _____

___ Neck

___ Forearm

___Thigh

14. Has child had high blood pressure or high cholesterol?

_____ _____

___ Back

___ W rist

___Knee

15. Has child ever been told he/she has a heart murmur?

_____ _____

___ Chest

___ Hand

___Shin/Calf

16. Has any family member or relative died of heart problems or sudden

_____ _____

death before age 50?

___ Shoulder

___ Finger

___ Ankle

17. Has child had severe viral infection (for example, myocarditis or

_____ _____

___ Upper Arm

___ Foot

mononucleosis) within the last month?

36. Does child want to weigh more or less than child weighs now?

_____ _____

18. Has a physician ever denied or restricted child’s participation in sports

_____ _____

for any heart problems?

_____ _____

37. Does child lose weight regularly to meet weight requirements for a

sport?

19. Does child have any current skin problems (for example, itching,

_____ _____

rashes, acne, warts, fungus, or blisters)?

38. Does child feel stressed out?

_____ _____

20. Has child ever had a head injury or concussion?

_____ _____

39. Record the dates of his/most recent immunizations (shots) for:

21. Has child ever been knocked out, become unconscious, or lost his/her

_____ _____

Tetanus__________________

Measles:___________________

memory?

Hepatitus B_______________

Chickenpox:________________

22. Has child ever had a seizure?

_____ _____

23. Does child have frequent or severe headaches?

_____ _____

24. Has child ever had numbness or tingling in his/her arms, hands, legs,

_____ _____

or feet?

25. Has child ever had a stinger, burner, or pinched nerve?

_____ _____

Explain “Yes” answers here: ______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

I hereby state, to the best of my knowledge, that my answers to the above questions are complete and correct.

Signature of Parent/Guardian___________________________________________________________________________

Date:___________________________________________