Ihsaa Athletic Physical Form
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4IHSAA PRE-PARTICIPATION PHYSICAL EVALUATION
SCHOOL:
HISTORY
Date:
Name:
Phone:
(
)
Address:
City:
Zip:
Sex:
Age:
Date of Birth:
Grade:
Personal Physician:
Phone:
(
)
Previous school attended and dates:
Explain "Yes" answers below:
Yes
No
1.
Have you ever been hospitalized? …………………………………………………………………………………………………………
Have you ever had surgery? …………………………………………………………………………………………………………………
Are you presently under a doctor's care? …………………………………………………………………………………………………….
2.
Are you presently taking any medications or pills? …………………………………………………………………………………………
3.
Do you have any allergies (medicines, bees, or other stinging insects)? ……………………………………………………………………
4.
Have you ever passed out during or after exercise? …………………………………………………………………………………………
Have you ever been dizzy during or after exercise? …………………………………………………………………………………………
Have you ever had chest pain during or after exercise? ……………………………………………………………………………………
Have you ever had high blood pressure? …………………………………………………………………………………………………….
Have you ever been told that you have a heart murmur? ……………………………………………………………………………………
Have you ever had racing of your heart or skipped heartbeats? ……………………………………………………………………………..
Has anyone in your family died of heart problems or a sudden death before age 50?………………………………………………………
Has anyone in your family had Marfan's syndrome? ………………………………………………………………………………………
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 or epilepsy? …………………………………………………………………………………………………
Have you ever had a stinger, burner, or pinched nerve? …………………………………………………………………………………….
7.
Have you ever had heat cramps, heat illness, or muscle cramps? …………………………………………………………………………
8.
Do you have trouble breathing or do you cough during or after the activity? ………………………………………………………………
9.
Do you use any special equipment (pads, braces, neck rolls, 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.
Are you missing an eye, kidney, or testicle? ………………………………………………………………………………………………
12.
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
Foot
Forearm
Shin/Calf
Back
Wrist
Ankle
Hip
Hand
13.
Have you had any other medical problems (infectious mononucleosis, diabetes, anemia, etc.)? …………………………………………...
14.
Have you had a medical problem or injury since your last evaluation? ………………………………………………………………..
15.
When was your last tetanus shot? _____________________________________________________________________________________________________
16.
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:____________________________________________________________________________________________
Date:___________________
Signature of parent/guardian:_____________________________________________________________________________________
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