Form Tma/tssaa - Preparticipation Medical Evaluation
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2TMA/TSSAA PREPARTICIPATION MEDICAL EVALUATION FORM
Page I of 2
Personal History
Name
Sex
Age
DOB
Grade
Sport(s)
School
Personal Physician
Address
Telephone
Have you every had a preparticipation physical before? ___ Yes ___ No If yes, when/where ______________
Please 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 allergies (medicine, bees or other stinging insects?
4. Have you every passed out during exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during exercise?
Do you tire more quickly than your friends during exercise?
Have you ever had high blood pressure?
Have you ever been told that you have a heart murmur?
Has anyone in your family died of heart problems or a sudden death before the age of 50?
5. Do you have any skin problems (itching, rashes, acne)?
6. Have you ever had a head injury?
Have you ever been knocked 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 activities?
9. Do you use any special equipment (pads, braces, neck role, mouth guard, eye guard)?
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 of any bones or joints?
_____ Head
_____ Shoulder
_____ Thigh
_____ Neck
_____ Elbow
_____ Knee
_____ Chest
_____ Forearm
_____ Shin/Calf
_____ Foot
_____ Back
_____ Wrist
_____ Ankle
_____ Hip
_____ Hand
12. Have you ever had any other medical problem (infectious mononucleosis, diabetes)?
13. Have you ever had a medical problem since your last evaluation?
14. When was your last tetanus shot?
When was your last measles shot?
15. When was your first menstrual period?
When was your last menstrual period?
When was the longest time between your periods last year?
Please explain “yes” answers here:
I herby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of Athlete
Signature of Parent/Guardian
Date
Signature of Coach
School
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Parent category: Medical