Questionnaire For Athletic Participation - Iowa Athletic Pre-Participation Physical Examination - 2012
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2IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION, Updated May 2012
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 neatly print this information)
Student’s Name _________________________________________ Male ___ 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 other side of this form after the examination.)
Yes
No
Does this student have / ever had?
Yes
No Does this student have / ever had?
1. _____ _____ Allergies to medication, pollen, stinging
20. _____ _____ Head injury, concussion, unconsciousness?
insects, food, etc.?
21. _____ _____ Headache, memory loss, or confusion with
2. _____ _____ Any illness lasting more than one (1) week?
contact?
3. _____ _____ Asthma or difficulty breathing during exercise?
22. _____ _____ Numbness, tingling or weakness in arms or
4. _____ _____ Chronic or recurrent illness or injury?
legs with contact?
5. _____ _____ Diabetes?
**************************************************************************
6. _____ _____ Epilepsy or other seizures?
23. _____ _____ Severe muscle cramps or illness when
7. _____ _____ Eyeglasses or contacts?
exercising in the heat?
8. _____ _____ Herpes or MRSA?
**************************************************************************
9. _____ _____ Hospitalizations (Overnight or longer)?
24. _____ _____ Fracture, stress fracture or dislocated
10. _____ _____ Marfan Syndrome?
joint(s)?
11. _____ _____ Missing organ (eye, kidney, testicle)?
25. _____ _____ Injuries requiring medical treatment?
12. _____ _____ Mononucleosis or Rheumatic fever?
26. _____ _____ Knee injury or surgery?
13. _____ _____ Seizures or frequent headaches?
27. _____ _____ Neck injury?
14. _____ _____ Surgery?
28. _____ _____ Orthotics, braces, protective equipment?
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29. _____ _____ Other serious joint injury?
15. _____ _____ Chest pressure, pain, or tightness with
30. _____ _____ Painful bulge or hernia in the groin area?
exercise?
31. _____ _____ X-rays, MRI, CT scan, physical therapy?
16. _____ _____ Excessive shortness of breath with exercise?
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17. _____ _____ Headaches, dizziness or fainting during, or
32. _____ _____ Has a doctor ever denied or restricted
after, exercise?
your participation in sports for any
18. _____ _____ Heart problems (Racing, skipped beats,
reason?
33. _____ _____ Do you have any concerns you would
murmur, infection, etc.?)
19. _____ _____ High blood pressure or high cholesterol?
like to discuss with your health care
provider?
Yes
No
Family History:
34. _____ _____ Does anyone in your family have Marfan syndrome?
35. _____ _____ Has anyone in your family died of heart problems or any unexpected/unexplained reason before the age of 50?
36. _____ _____ Does anyone in your family have a heart problem, pacemaker or implanted defibrillator?
37. _____ _____ Has anyone in your family had unexplained fainting, seizures, or near drowning?
38. _____ _____ Does anyone in your family have asthma?
39. _____ _____ Do you or someone in your family have sickle cell trait or disease?
Use this space to explain any “YES” answers from above (questions #1-38) or to provide any additional information:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
40. Are you allergic to any prescription or over-the-counter medications? If yes, list: _____________________________________
41. List all medications you are presently taking (including asthma inhalers & EpiPens) and the condition the medication is for:
A. ________________________________ B. _______________________________ C. _________________________________
42. Year of last known vaccination:
Tetanus: _________
Meningitis: __________
Influenza: __________
43. What is the most and least you have weighed in the past year? Most __________________ Least ______________________
44. Are you happy with your current weight? Yes _____ No _____ If no, how many pounds would you like to lose or gain?
Lose _____ Gain _____
FOR FEMALES ONLY:
1. How old were you when you had your first menstrual period? ____________________
2. How many periods have you had in the last 12 months? _______________________
Page 1 of 2, Physical Examination Record & Parent’s/Guardian’s Release is on the reverse side
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