High School Athletic Pre Participation Exam Form
ADVERTISEMENT
1
2HIGH SCHOOL ATHLETIC PRE-PARTICIPATION EXAM FORM
Circle One: IHS NHS UHS WHS
Name:
Grade:
M/F
(PRINT LEGIBLY)
Last
First
Middle or Nickname
(In Fall)
Circle
Birthdate:
Student ID #:
SPORT: ________Fall ________Winter ________Spring
Section A: REQUIRED HEALTH HISTORY TO BE COMPLETED BY PARENT OR GUARDIAN
Has your child:
↓ If you answer “YES” to any questions, please explain below↓
1.
Had a medical illness or injury that has disqualified him/her from athletic participation?
YES
NO
2.
Ever been hospitalized or undergone any surgical operations(s)?
YES
NO
3.
Had an ongoing chronic or serious illness (such as diabetes, kidney problems, seizures or asthma)?
YES
NO
4.
Ever taken any supplements or vitamins to help gain/lose weight or improve athletic performance?
YES
NO
5.
Ever passed out during/after exercise or become ill from exercising?
YES
NO
6.
Ever tired earlier than expected during exercise or complained of extreme fatigue?
YES
NO
7.
Ever had chest pain or unusual/irregular heartbeats during or after exercise?
YES
NO
8.
Had any history of heart problems, heart murmur, high blood pressure or high cholesterol?
YES
NO
9.
Had any family member or relative die before the age of 50 or die of heart-related problems?
YES
NO
10.
Had any family history of specific heart issues? If “YES,” check all that apply:
YES
NO
Hypertrophic Cardiomyopathy
Arrhythmia
Marfan’s Syndrome
Long QT Syndrome
11.
Had any history of concussion, head injury, loss of memory or being unconscious?
YES
NO
12.
Had any history of seizures, convulsions or fainting episodes?
YES
NO
13.
Had frequent or severe headaches?
YES
NO
14.
Ever had a “stinger,” “burner,” or pinched nerve (numbness or tingling down an extremity)?
YES
NO
15.
Had any problems with vision that require glasses, contacts, or protective eyewear?
YES
NO
16.
Had special protective or corrective equipment/devices that are not usually used for sports?
YES
NO
Examples: knee brace, neck roll, foot orthotics, retainer for teeth, hearing aids?
17.
Been diagnosed with a contagious skin condition within the past month?
YES
NO
18.
Ever broken/fractured any bones or dislocated any joints?
YES
NO
19.
Had any recurring problems with pain or swelling in back, muscles, tendons, bones or joints?
YES
NO
20.
Is your child currently under the care of a physician for any medical, orthopedic or emotional concerns?
YES
NO
21.
Had any history of asthma, allergies to foods, medicines, or stinging insects?
YES
NO
If “YES,” what medications are used? Is Epi-Pen needed?
22.
Does your child require any special health procedure(s) during the regular school day or during athletics?
YES
NO
23.
Is your child currently taking any prescription or “over-the-counter” medications or using an inhaler or Epi-Pen?
YES
NO
If “YES,” list all medications:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
If you have answered “YES” to any of the above questions, please explain:
___________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Date: __________ Signature of Parent/Guardian: _______________________ Signature of Student:______________________
Section B: PHYSICAL EXAM REQUIRED FOR ALL ATHLETES: To be completed by HEALTHCARE PROVIDER
Normal
Normal
General:
Chest/Lungs
Visual acuity (Distance): Right:
/
Left:
/
Eyes, ears, nose, throat
Neck
Corrected
Uncorrected
Cardiovascular
Abdomen
Height:
Blood pressure:
Femoral pulses
Skin
Weight:
Pulse:
Comments:
Recommendation:
Full activity-No restrictions
Activity with restrictions
No contact sports
No participation
Other
Examining Healthcare Provider (please print): _________________________________________
Healthcare Provider Office Stamp:
Signature: ______________________________________________
DATE OF EXAM:____________ Phone: ________________
Section C: MUSCULOSKELETAL SCREENING FOR ALL ATHLETES: Highly recommend for completion by an ORTHOPEDIC SURGEON/
SPORTS MEDICINE SPECIALIST at your child’s High School. (This may be completed by your HEALTHCARE PROVIDER)
Comments:
Musculoskeletal:
Normal
Normal
Normal
Neck/Shoulder
Hips/Thighs
Arms/Hands
Spine
Knees
Ankles/Feet
Recommendation:
Full activity-No restrictions
Activity with restrictions
No contact sports
No participation
Other
Signature HEALTHCARE PROVIDER : __________________________________________ DATE OF EXAM: _____________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical