Pre-Participation Physical Evaluation Page 2
ADVERTISEMENT
1
2History
Date ___________
Name _______________________________ Sex _____ Age ______ Date of Birth ____________
Grade _________ Sport _________________
________________
__________________
Person Physician _________________________ _______________________________ ___________
Address
Phone Number
Explain “Yes” answers below:
Yes
No
…………………………………………………………… □
□
1. Have you ever been hospitalized?
………….…………………………………………………...… □
□
Have you ever had surgery?
?……........................................................ □
□
2. Are you presently taking any medications or pills
………………………….. □
□
3. Do you have any allergies (medicine, bees or other stinging insects?
………………………………………… □
□
4. Have you ever been past out during or after exercise?
…………………………………………… □
□
Have you ever been dizzy during or after exercise?
…………..…………………………… □
□
Have you ever had chest pain during or after exercise?
…………………………………… □
□
Do you tire more quickly than your friends during exercise?
……………...……………………………………… □
□
Have you ever had high blood pressure?
………………………………… □
□
Have you ever been told that your have a heart murmur?........
………….……………………… □
□
Have you ever had racing of your heart or skipped heartbeat?
… □
□
Has anyone in your family died of heart problems or a sudden death before age 50?.................
...…..………………………………… □
□
5. Do you have any skin problems (itching, rashes, acne)?
……………………..……………………………………… □
□
6. Have you ever had a head injury?
……..……………………………………… □
□
Have you ever been knocked out or unconscious?
………………………………………………………………… □
□
Have you ever had a seizure?
………………………………………… □
□
Have you ever had a stinger, burner or pinched nerve?
…………………………………………………… □
□
7. Have you ever had heat or muscle cramps?
…..……………………………………… □
□
Have you ever been dizzy or passed out in the heat?
………………………… □
□
8. Do you have trouble breathing or do you cough during or after activity?
.....… □
□
9. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc?
….……………………………………,… □
□
10. Have you had any problems with your eyes or vision?
…………………………………….… □
□
Do you wear glasses or contacts or protective eye wear?
11. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other
………………………………………………………………… □
□
injuries of any bones or joints?
□
□
□
□
□
□
□
Head
Shoulder
Thigh
Neck
Elbow
Knee
Chest
□
□
□
□
□
□
□
□
Forearm
Shin/calf
Back
Wrist
Ankle
Hip
Hand
Foot
………… □
□
12. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)?
…….…………………… □
□
13. Have you had a medical problem or injury since your last evaluation?
……………………….…………………………………… □
□
14. When was your last tetanus shot?
…………,,,,,,,,,,,,,……………………………… □
□
When was your last measles immunization?
…………………..…………………………………… □
□
15. When was your first menstrual period?
…………………………..…………………………… □
□
When was your last menstrual period?
…………………………………… □
□
What was the longest time between your periods last year?
Explain “Yes” answers:
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Date _________________
Signature of athlete _____________________________________
Signature of parent/guardian __________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Section 5: Health History, Section 6: Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
Education
Section 6: Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
Education
Athletic Pre-participation Physical Evaluation Form - Archdiocese Of Miami, Department Of Schools
Business
Related Categories
Parent category: Medical