Iowa Athletic Pre-Participation Physical Examination Form
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2IOWA ATHLETIC 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 o f physical
examination.
QUESTIONNAIRE FOR ATHLETIC PARTICIPATION (Please type or neatly print this information)
Student’s Name
__
Male
Female
Date of Birth
Grade
Home Address
_ School District
(Street, City, Zip)
Parent’s/Guardian’s Name
Date
Phone #
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?
21.
Headache, memory loss, or confusion with
insects, food, etc.?
contact?
2.
Any illness lasting more than one (1) week?
22.
Numbness, tingling or weakness in arms or
3.
Asthma or difficulty breathing during exercise?
legs with contact?
4.
Chronic or recurrent illness or injury?
**************************************************************************
5.
Diabetes?
23.
Severe muscle cramps or illness when
6.
Epilepsy or other seizures?
exercising in the heat?
7.
Eyeglasses or contacts?
**************************************************************************
8.
Herpes or MRSA?
24.
Fracture, stress fracture or dislocated
9.
Hospitalizations (Overnight or longer)?
joint(s)?
10.
Marfan Syndrome?
25.
Injuries requiring medical treatment?
11.
Missing organ (eye, kidney, testicle)?
26.
Knee injury or surgery?
12.
Mononucleosis or Rheumatic fever?
13.
Seizures or frequent headaches?
27.
Neck injury?
28.
Orthotics, braces, protective equipment?
14.
Surgery?
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?
**************************************************************************
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.?)
like to discuss with your health care
19.
High blood pressure or high cholesterol?
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:
Tdap (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 Permission and Release is on the reverse side
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