Preparticipation Physical Evaluation Form
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1
2
3Revised 7/1/05
Mandatory
Preparticipation Physical Evaluation
HISTORY FORM
Date of Exam ___________________________
Name _________________________________________ Sex_________Age________Date of birth_________________
Grade_____School________________________________Sport(s)____________________________________________
Address_________________________________________________________________Phone_____________________
Personal Physician __________________________________________________________________________________
In case of emergency, contact:
Name _______________________Relationship______________Phone (H)_______________Phone(W)______________
Explain "Yes" answers below.
Circle questions you don't know the answers to.
Yes No
Yes No
1. Has a doctor ever denied or restricted your participation
24. Do you cough, wheeze, or have difficulty breathing
in sports for any reason?
during or after exercise?
2. Do you have an ongoing medical condition
25. Is there anyone in your family who has asthma?
(like diabetes or asthma)?
26. Have you ever used an inhaler or taken asthma medicine?
3. Are you currently taking any prescription or
27. Were you born without or are you missing a kidney,
nonprescription (over-the-counter) medicines or pills?
an eye, a testicle, or any other organ?
4. Do you have allergies to medicines, pollens, foods, or
28. Have you had infectious mononucleosis (mono)
stinging insects?
within the last month?
5. Have you ever passed out or nearly passed out
29. Do you have any rashes, pressure sores, or other
DURING exercise?
skin problems?
6. Have you ever passed out or nearly passed out
30. Have you had a herpes skin infection?
AFTER exercise?
31. Have you ever had a head injury or concussion?
7. Have you ever had discomfort, pain, or pressure in
32. Have you been hit in the head and been confused
your chest during exercise?
or lost your memory?
8. Does your heart race or skip beats during exercise?
33. Have you ever had a seizure?
9. Has a doctor ever told you that you have
34. Do you have headaches with exercise?
(check all that apply):
35. Have you ever had numbness, tingling, or weakness
High blood pressure
A heart murmur
in your arms or legs after being hit or falling?
High cholesterol
A heart infection
36. Have you ever been unable to move your arms or
10. Has a doctor ever ordered a test for your heart?
legs after being hit or falling?
(for example: ECG, echocardiogram)
37. When exercising in the heat, do you have severe
11. Has anyone in your family died for no apparent reason?
muscle cramps or become ill?
12. Does anyone in your family have a heart problem?
38. Has a doctor told you that you or someone in your
13. Has any family member or relative died of heart
family has sickle cell trait or sickle cell disease?
problems or of sudden death before age 50?
39. Have you had any problems with your eyes or vision?
14. Does anyone in your family have Marfan syndrome?
40. Do you wear glasses or contact lenses?
15. Have you ever spent the night in a hospital?
41. Do you wear protective eyewear, such as goggles or
16. Have you ever had surgery?
a face shield?
17. Have you ever had an injury, like a sprain, muscle or
42. Are you happy with your weight?
ligament tear, or tendinitis, that caused you to miss a
43. Are you trying to gain or lose weight?
practice or game? If yes, circle affected area below:
44. Has anyone recommended you change your weight
18. Have you had any broken or fractured bones or
or eating habits?
dislocated joints? If yes, circle below:
45. Do you limit or carefully control what you eat?
19. Have you had a bone or joint injury that required x-rays
46. Do you have any concerns that you would like to
MRI, CT, surgery, injections, rehabilitation, physical
discuss with a doctor?
therapy, a brace, a cast, or crutches? If yes, circle below:
FEMALES ONLY
Head
Neck
Shoulder
Upper
Elbow
Forearm
Hand/
Chest
47. Have you ever had a menstrual period?
Arm
Fingers
48. How old were you when you had your first menstrual period? ______
Upper
Lower
Hip
Thigh
Knee
Calf/
Ankle
Foot/
49. How many periods have you had in the last 12 months?__________
Back
Back
Shin
Toes
Explain "Yes" answers here:_________________________________
20. Have you ever had a stress fracture?
__________________________________________________________
21. Have you been told that you have or have you had
__________________________________________________________
an x-ray for atlantoaxial (neck) instability?
__________________________________________________________
22. Do you regularly use a brace or assistive device?
__________________________________________________________
23. Has a doctor ever told you that you have asthma
__________________________________________________________
or allergies?
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_____________
c
2004 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American
Osteopathic Academy of Sports Medicine.
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