Pre-Participation History & Health Assessment Form Page 2
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2Pre-Participation Physical Evaluation Medical History Questionnaire
Note: This form is to be filled out by the parent(s) and student prior to seeing the physician.
Student’s Name _________________________________________________
Today’s Date ___________________
Attention parent or guardian and athlete: answers to the following questions are very important! Please take the time to ans wer
each question to the best of your knowledge. Explain “Yes” answers below. Circle question if you do not know the answer.
General Questions
Yes No
25. Do you have any history of juvenile arthritis or connective tissue
disease?
1. Has a doctor ever denied or restricted your participation
Medical Questions
Yes No
in sports for any reason?
2. Do you have any ongoing medical conditions, If so
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
Identify:
Asthma
Anemia
Diabetes
Infections
Other: ___________________________________________
27. Have you ever used an inhaler or taken asthma medicine?
3. Have you ever spent the night in the hospital?
28. Is there anyone in your family who has asthma?
4. Have you ever had surgery?
29. Were you born without or are you missing a kidney, an eye, a
testicle (males), your spleen, or any other organ?
Heart Heath Questions About You
Yes No
30.
Do you have groin pain or a painful bulge or hernia in the groin area?
5. Have you ever passed out or nearly passed out during or after
exercise?
31. Have you had infectious mononucleosis (mono) in the last month?
6. Have you ever had pain, discomfort, tightness, or pressure in
32. Do you have any rashes, pressure sores, or other skin problems?
your chest during exercise?
33. Have you had a herpes or MRSA skin infection?
7. Does your heart ever race or skip a beat (irregular beats)
during exercise?
34. Do you have a history of seizure disorder?
8. Has a doctor ever told you that you have any heart
35. Do you have headaches with exercise?
problems? If so, check all that apply:
36. Have you ever had numbness, tingling, or weakness in your arms
High Blood Pressure
A heart murmur
or legs after being hit or falling?
High cholesterol
A heart infection
Kawasaki disease
Other: ___________________
37. Have you ever been unable to move your arms or legs after being
hit or falling?
9. Has a doctor ever ordered a test for your heart?
38. Have you ever become ill while exercising in the heat?
10. Do you get lightheaded or feel more short of breath
more than expected during exercise?
39. Do you get frequent muscle cramps when exercising?
11. Have you ever had an unexplained seizure?
40. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your
41. Have you had any problems with your eyes or vision?
friends during exercise?
42. Have you had any eye injuries?
Health Questions About Your Family
Yes No
43. Do you wear glasses or contact lenses?
13.
Has any family member or relative died of heart problems
44. Do you wear protective eyewear, such as goggles or a face shield?
or had an unexpected sudden death before age 50
(including drowning, unexplained car accident, sudden death syndrome)?
45. Do you worry about your weight?
14.
Does anyone in your family have hypertrophic cardiomyopathy,
46. Are you trying or has anyone recommended that you gain or lose
Marfan syndrome, short QT syndrome, Brugada syndrome, or
weight?
catecholaminergic, polymorphic ventricular tachycardia?
47. Are you on a special Diet or do you avoid certain types of foods?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator?
48. Have you ever had an eating disorder?
16. Has anyone in your family had unexplained fainting,
49. Do you have any concerns that you would like to discuss with a
unexplained seizures or near drowning?
doctor?
Bone and Joint Questions
Yes No
Females Only
Yes No
17. Have you ever had an injury to a bone, muscle, ligament or
50. Have you ever had a menstrual period?
tendon that caused you to miss a game or practice?
51. How old were you when you had your first menstrual period?
18. Have you ever had any broken or fractured bones or
dislocated joints?
52. How many periods have you had in the past 12 months?
19. Have you ever had an injury that required x-rays, MRI,
CT scan, injections, therapy, a brace, cast, or crutches?
Explain any “YES” answers on an additional page and attach to
this questionnaire.
20. Have you ever had a stress fracture?
21. Do you regularly use a brace, orthotics, or other assistive device?
I hereby state that, to best of my knowledge, my answers to the
above questions are complete and correct.
22. Have you ever been told that you have or have you had an x-ray
for neck instability or atlantoaxial instability? (Down syndrome
Athlete’s Signature ____________________________________
or dwarfism)
_________________________________
Parent/Guardian Signature
23. Do you have a bone, muscle, or joint injury that bothers you?
Date ______________________________
24.
Do any of your joints become painful, swollen, feel warm, or look red?
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