Athletic Pre-Participation Physical Examination - Davenport Community School District, Iowa
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2DAVENPORT COMMUNITY SCHOOL DISTRICT
ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION
The certificate of physical examination is valid for the purpose of this rule for one calendar year. A grace period not to exceed
thirty days is allowed for expired certifications of physical examination.
QUESTIONNAIRE FOR ATHLETIC PARTICIPATION (Please Print)
SCHOOL ______________________________
NAME _________________________________ MALE_____ FEMALE _____ DATE OF BIRTH ____________ GRADE ________
HOME ADDRESS ____________________________________________________ PHONE # ______________________________
PARENT'S NAME ____________________________________________ FAMILY PHYSICIAN ____________________________
WORK # ________________________________ EMERGENCY CONTACT # __________________________________________
EMERGENCY CONTACT PERSON ____________________________________________________________________________
HEALTH HISTORY (Student Athlete or Parent/Guardian to Fill Out #1 - 31 Before Exam)
(Parent/Guardian Required to Sign on Back of the Form After Examination.)
Yes
No
Has This Student Had Any?
Yes
No
Has This Student Had Any?
1. _____
_____ Chronic or recurrent illness?
14. _____
_____ Asthma?
2. _____
_____ Hospitalizations?
15. _____
_____ Epilepsy?
3. _____
_____ Surgery, other than tonsillectomy?
16. _____
_____ Diabetes?
4. _____
_____ Missing organs (eye, kidney, testicle)?
17. _____
_____ Eyeglasses or contact lenses?
5. _____
_____ Allergy to medications?
18. _____
_____ Dental braces, bridges, plates?
6. _____
_____ Problems with heart or blood pressure?
7. _____
_____ Chest pain with exercise?
Yes
No
Is there a history of?
8. _____
_____ Dizziness or fainting with exercise?
19. _____
_____ Injuries requiring medical treatment?
9. _____
_____ Frequent headaches, convulsions,
20. _____
_____ Neck injury?
dizziness or fainting?
21. _____
_____ Knee injury?
10. _____
_____ Concussion or unconsciousness?
22. _____
_____ Knee surgery?
11. _____
_____ Heat exhaustion, heat stroke, or
23. _____
_____ Ankle injury?
other heat problems?
24. _____
_____ Other serious joint injury?
12. _____
_____ Any illness lasting over a week?
25. _____
_____ Broken bones (fractures)?
13. _____
_____ Rheumatic fever?
Yes
No
Further History:
26. _____
_____ Is there any history of family or genetic disease?
27. _____
_____ Has any family member died suddenly at less than 40 years of age of causes other than an accident?
28. _____
_____ Has any family member had a heart attack at less than 55 years of age?
29. _____
_____ Are you uncomfortably short of breath after running 1/2 mile (2 times around the track) without stopping?
30. List all medications you are presently taking and what condition the medication is for.
A.
B.
C.
31. What is the most and the least you have weighed in the past year? Most ____________/Least____________
Date of last known tetanus (lockjaw) shot: ______________________
FOR WOMEN ONLY:
1. How old were you when you had your first menstrual period? ___________________
2. In the past year, what is the longest time you have gone between menstrual periods? ___________________
Use this space to explain any of the above numbered YES answers or to provide any additional information:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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