Athletic Pre-Participation - Physical Examination Form
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1
2ATHLETIC PRE-PARTICIPATION
PHYSICAL EXAMINATION
ARTICLE VII 36.14(1) PHYSICAL EXAMINATION.
Every year each student (grades 7-12) shall
Present to the student’s superintendent a certificate signed by a licensed physician and surgeon, osteopathic physician and surgeon,
osteopath, advanced registered nurse practitioner (ARNP), physician’s assistant or qualified doctor of chiropractic, to the effect that
the student has been examined and may safely engage in athletic competition.
This certificate of physical examination is valid for the purposes of this rule for one (1) calendar year. A grace period, not to exceed
thirty (30) days, is allowed for expired certifications of physical examination.
QUESTIONNAIRE FOR ATHLETIC PARTICIPATION (Please type or print this information).
Name ___________________________________________________ Make ___ Female ___ Date of Birth ________ Grade _____
Home Address ____________________________________________________________ Phone # ___________________________
Parent’s/Guardian’s Name _____________________________________________________ Date __________________________
Family Physician ___________________________________________________________ Phone # _________________________
HEALTH HISTORY (The following questions should be completed by the student-athlete with the assistance of a parent or
guardian. A parent or guardian is required to sign on the back of this form after the physical examination is completed)
Yes
No
Has this student had any?
Yes
No
Has this student had any?
1. _____ _____ Chronic or recurrent illness or injury?
15. _____ _____ Asthma?
2. _____ _____ Any illness lasting more than one (1) week?
16. _____ _____ Epilepsy or other seizures?
3. _____ _____ Rheumatic fever, mononucleosis?
17. _____ _____ Diabetes?
4. _____ _____ Hospitalizations (Overnight or longer)?
18. _____ ______ Eyeglasses or contact lenses?
5. _____ _____ Surgery, other than tonsillectomy?
19. _____ ______ Dental braces, bridges, plates?
6. _____ _____ Missing organs (eye, kidney, testicle)?
7. _____ _____ Allergy to medications, insects, food?
8. _____ _____ Seasonal Allergies (hay fever)?
Yes
No
Is there a history of?
9. _____ _____ Problems with heart, blood pressure, cholesterol?
20. _____ _____ Injuries requiring medical treatment?
10._____ _____ Racing of your heart or skipped heart beats?
21. _____ _____ Neck injury?
11._____ _____ Chest pain with exercise?
22. _____ _____ Knee injury?
12._____ _____ Frequent headaches, convulsions, dizziness, fainting? 23. _____ _____ Knee surgery?
13._____ _____ Dizziness or fainting with exercise?
24. _____ _____ Ankle injury?
14._____ _____ Concussion, unconsciousness, extremity numbness?
25. _____ _____ Broken bones (fractures)?
15._____ _____ Heat exhaustion, heat stroke, or other heat related
26. _____ _____ Other serious joint injuries?
Problems
27. _____ _____ Use of protective equipment or braces?
Yes
No
Further History:
28._____ _____ Is there a history of family or genetic disease?
29._____ _____ Has any family member died suddenly at less than 40 years of age of causes other than an accident?
30._____ _____ Has any family member had a heart attack at less than 55 years of age?
31._____ _____ Are you uncomfortably short of breath after running 1/2 mile (2 times around a track) without stopping?
32._____ _____ List all medications you are presently taking, including asthma inhalers, and the condition the medication is for:
A.
B.
C.
33. What is the most and least you have weighed in the past year? Most______________________ Least______________________
Date of last known tetanus (lockjaw) shot: ________________________________
FOR WOMEN ONLY:
1.
How old were you when you had your first menstrual period? __________________________________________________
2.
In the past year, what is the longest time you have gone between menstrual periods? ________________________________
Use this space to explain any of the above numbered YES answers or to provide additional information:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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