North Carolina High School Athletic Association Sport Preparticipation Examination Form
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2NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION
SPORT PREPARTICIPATION EXAMINATION FORM
Patient’s Name: ____________________________________________________
Age: ______
Sex: _____
This is a screening examination for participation in sports. This does not substitute for a comprehensive
examination with your child’s regular physician where important preventive health information can be covered.
Athlete’s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your
knowledge.
Parent’s Directions: Please assure that all questions are answered to the best of your knowledge. If you do not understand or
don’t know the answer to a question please ask your doctor. Not disclosing accurate information may put your child at risk during
sports activity.
Physician’s Directions: We recommend carefully reviewing these questions and clarifying any positive or Don’t Know answers.
Explain “Yes” answers below
Yes
No
Don’t
know
1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, etc.]?
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List:
2. Is the athlete presently taking any medications or pills?
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3. Does the athlete have any allergies (medicine, bees or other stinging insects, latex)?
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4. Does the athlete have the sickle cell trait?
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5. Has the athlete ever had a head injury, been knocked out, or had a concussion?
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6. Has the athlete ever had a heat injury (heat stroke) or severe muscle cramps with activities?
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7. Has the athlete ever passed out or nearly passed out DURING exercise, emotion or startle?
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8. Has the athlete ever fainted or passed out AFTER exercise?
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9. Has the athlete had extreme fatigue (been really tired) with exercise (different from other children)?
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10. Has the athlete ever had trouble breathing during exercise, or a cough with exercise?
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11. Has the athlete ever been diagnosed with exercise-induced asthma ?
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12. Has a doctor ever told the athlete that they have high blood pressure?
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13. Has a doctor ever told the athlete that they have a heart infection?
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14. Has a doctor ever ordered an EKG or other test for the athlete’s heart, or has the athlete ever been told they have a
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murmur?
15. Has the athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of their
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heart “racing” or “skipping beats”?
16. Has the athlete ever had a seizure or been diagnosed with an unexplained seizure problem?
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17. Has the athlete ever had a stinger, burner or pinched nerve?
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18. Has the athlete ever had any problems with their eyes or vision?
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19. Has the athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of
any bones or joints?
q Head
q Shoulder
q Thigh
q Neck
q Elbow
q Knee
q Chest
qHip
q Forearm q Shin/calf
q Back
q Wrist
q Ankle
q Hand
q Foot
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20. Has the athlete ever had an eating disorder, or do you have any concerns about your eating habits or weight?
21. Has the athlete ever been hospitalized or had surgery?
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22. Has the athlete had a medical problem or injury since their last evaluation?
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FAMILY HISTORY
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23. Has any family member had a sudden, unexpected death before age 50 (including from sudden infant death
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syndrome [SIDS], car accident, drowning)?
24. Has any family member had unexplained heart attacks, fainting or seizures?
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25. Does the athlete have a father, mother or brother with sickle cell disease?
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_________________________________________________________________
Elaborate on any positive (yes) answers:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
By signing below I agree that I have reviewed and answered each question above. Every question is answered completely and is
correct to the best of my knowledge. Furthermore, as parent or legal custodian, I give consent for this examination and give
permission for my child to participate in sports.
Signature of parent/legal custodian: ________________________________________ Date: __________________
Signature of Athlete: _______________________________Date: __________________Phone #: ________________
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