Ihsaa Pre Participation Physical Evaluation Form printable pdf download

IHSAA 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 (medicine, 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 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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