Section 5: Health History, Section 6: Piaa Comprehensive Initial Pre-Participation Physical Evaluation And Certification Of Authorized Medical Examiner
ADVERTISEMENT
1
2Student’s Name
Age
Grade
S
5: H
H
ECTION
EALTH
ISTORY
Explain “Yes” answers at the bottom of this form.
Circle questions you don’t know the answers to.
Yes
No
Yes
No
23.
Has a doctor ever told you that you have
1.
Has a doctor ever denied or restricted your
participation in sport(s) for any reason?
asthma or allergies?
24.
Do you cough, wheeze, or have difficulty
2.
Do you have an ongoing medical condition
(like asthma or diabetes)?
breathing DURING or AFTER exercise?
25.
Is there anyone in your family who has
3.
Are you currently taking any prescription or
nonprescription (over-the-counter) medicines
asthma?
26.
Have you ever used an inhaler or taken
or pills?
4.
Do you have allergies to medicines,
asthma medicine?
27.
Were you born without or are your missing
pollens, foods, or stinging insects?
5.
Have you ever passed out or nearly
a kidney, an eye, a testicle, or any other
passed out DURING exercise?
organ?
6.
Have you ever passed out or nearly
28.
Have you had infectious mononucleosis
(mono) within the last month?
passed out AFTER exercise?
7.
Have you ever had discomfort, pain, or
29.
Do you have any rashes, pressure sores,
or other skin problems?
pressure in your chest during exercise?
8.
Does your heart race or skip beats during
30.
Have you ever had a herpes skin
exercise?
infection?
9.
Has a doctor ever told you that you have
CONCUSSION OR TRAUMATIC BRAIN INJURY
(check all that apply):
31.
Have you ever had a concussion (i.e. bell
High blood pressure
Heart murmur
rung, ding, head rush) or traumatic brain
High cholesterol
Heart infection
injury?
10.
Has a doctor ever ordered a test for your
32.
Have you been hit in the head and been
heart? (for example ECG, echocardiogram)
confused or lost your memory?
11.
Has anyone in your family died for no
33.
Do you experience dizziness and/or
apparent reason?
headaches with exercise?
12.
Does anyone in your family have a heart
34.
Have you ever had a seizure?
problem?
35.
Have you ever had numbness, tingling, or
13.
Has any family member or relative been
weakness in your arms or legs after being hit
disabled from heart disease or died of heart
or falling?
problems or sudden death before age 50?
36.
Have you ever been unable to move your
14.
Does anyone in your family have Marfan
arms or legs after being hit or falling?
syndrome?
37.
When exercising in the heat, do you have
15.
Have you ever spent the night in a
severe muscle cramps or become ill?
hospital?
38.
Has a doctor told you that you or someone
16.
Have you ever had surgery?
in your family has sickle cell trait or sickle cell
17.
Have you ever had an injury, like a sprain,
disease?
muscle, or ligament tear, or tendonitis, which
39.
Have you had any problems with your
caused you to miss a Practice or Contest?
eyes or vision?
If yes, circle affected area below:
40.
Do you wear glasses or contact lenses?
18.
Have you had any broken or fractured
41.
Do you wear protective eyewear, such as
bones or dislocated joints? If yes, circle
goggles or a face shield?
below:
42.
Are you unhappy with your weight?
19.
Have you had a bone or joint injury that
43.
Are you trying to gain or lose weight?
required x-rays, MRI, CT, surgery, injections,
44.
Has anyone recommended you change
rehabilitation, physical therapy, a brace, a
your weight or eating habits?
cast, or crutches? If yes, circle below:
45.
Do you limit or carefully control what you
Head
Neck
Shoulder
Upper
Elbow
Forearm
Hand/
Chest
eat?
arm
Fingers
46.
Do you have any concerns that you would
Upper
Lower
Hip
Thigh
Knee
Calf/shin
Ankle
Foot/
like to discuss with a doctor?
back
back
Toes
FEMALES ONLY
20.
Have you ever had a stress fracture?
21.
Have you been told that you have or have
47.
Have you ever had a menstrual period?
you had an x-ray for atlantoaxial (neck)
48.
How old were you when you had your first
menstrual period?
instability?
22.
Do you regularly use a brace or assistive
49.
How many periods have you had in the
device?
last 12 months?
50.
Are you pregnant?
#’s
Explain “Yes” answers here:
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Student’s Signature _________________________________________________________________________Date____/____/_____
I hereby certify that to the best of my knowledge all of the information herein is true and complete.
Parent’s/Guardian’s Signature _________________________________________________________________Date____/____/_____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Section 6: Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
Education
Piaa Comprehensive Initial Pre-participation Physical Evaluation And Certification Of Authorized Medical Examiner
Business
Related Categories
Parent category: Education