Sports Pre-Participation Exam Form printable pdf download

ALL FOR KIDS PEDIATRIC CLINIC

Little Rock, Arkansas

SPORTS PRE-PARTICIPATION EXAM

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KEY:

Normal

Abnormal (See comments)

Not Addressed

Name:____________________________________________________

Measurements:



Weight___________

____________%ile

Age in years:____________________ Date:____________________

Sports History:

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Height

_____________

____________%ile

YES NO

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Has anyone in the athlete's family died suddenly before the age of 50

Blood Pressure: ________/__________

years?

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Has the athlete ever passed out during exercise or stopped exercising

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Heart Rate:

_________

because of dizziness or chest pain?

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Does the athlete have asthma (wheezing), hay fever, or coughing

Physical Exam (nl = normal, abnl = abnormal):

spells during or after exercise?

abnl

(If abnormal give details below)

 

Has the athlete ever broken a bone, had to wear a cast, or had an

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injury to any joint?

1. General, development, nourishment

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Does the athlete have a history of a consussion (getting knocked out)

2. Head, face, scalp

or seizures?

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3. Eyes

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Has the athlete ever suffered a heat-related illoness (heat stroke)?

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4. Ears, Tympanic Membranes, hearing

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Does the athlete have a chronic illness or see a physician regularly for

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5. Nose, Mouth, Pharynx

any particular problem?

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6. Neck, thyroid

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Does the athlete take any prescribed medicine, herbs or nutritional

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7. Lungs, clear to ausculatation, chest symmetry

supplements?

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8. Breasts, Tanner stage

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Is the athlete allergic to any medications or bee stings?

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9. Heart, rate, rhythm, no murmur, pulses normal

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Does the athlete have only one of any paired organ (eyes, ears, kid-

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neys, testicles, ovaries, etc.)?

10. Abdomen, soft, no masses, LSK not enlarged

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Has the athlete ever had prior limitaion from sports participation?

11. Genitals, Tanner stage

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Has the athlete had any episodes of shortness of breath, palpitations,

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12. Skin

history or rheumatic fever or unusual fatigability?

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13. Neuro, CN intact, DTR's normal, coordination

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Has the athlete ever been diagnosed with a heart murmur or heart

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14. Bones, Joints, Extremities

condition or hypertension?

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15. Scoliosis screen, Scoliometer ________degrees

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Is there a history of young people in the athlete's family who have

had congential or other heart disease: cardiomypath, abnormal heart

__________________________________________________________

rhythms, long QT or Marfan's syndrome?(You may write "I don't

understand these terms" and initial this item, if appropriate.)

___________________________________________________________

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Has the athlete ever been hospitalized overnight or had surgery?

__________________________________________________________

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Does the athlete lose weight regularly to meet the requirements for

your sport?

__________________________________________________________

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Does the athlete have anything he or she wants to discuss with the

physician?

ASSESSMENT:

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Does the athlete cough, wheeze, or have trouble breathing during or

after activity?

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Cleared for sports participation

FEMALES ONLY:

a. When was your first menstrual period? _________

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Not Cleared

b. When was your most recent menstrual period? _________

c. What was the longerst time between periods in the last year? _____

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Cleared after evaluation for _________________________

Signature_____________________________________Date_____________

Other History:________________________________________________

PLAN:

_____________________________________________________________

All For Kids Form revised 1-4-10

Sports Pre-Participation Exam Form

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