Athletic Participation/parental Consent/physical Examination Form Page 2
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4Revised March 2013
The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician
Page 2 of 4
PART II - - MEDICAL HISTORY-
Explain “Yes” answers below
This form must be completed and signed, prior to the physical examination, for review by examining practitioner.
Explain “Yes” answers below with number of the question. Circle questions you don’t know the answers to.
GENERAL MEDICAL HISTORY
Yes
No
MEDICAL QUESTIONS
Yes
No
(cont)
1. Has a doctor ever denied or restricted your participation in
29. Do you have groin pain or a painful bulge or hernia in
sports for any reason?
the groin area?
2. Do you currently have an ongoing medical condition? If so,
Please identify:
Asthma
Anemia
Diabetes
30. Have you had mononucleosis (mono) within the last
Infections
Other:
month?
3. Have you ever spent the night in the hospital?
31. Do you have any rashes, pressure sores, or other skin
problems?
4. Have you ever had surgery?
32. Have you ever had a herpes or MRSA skin infection?
HEART HEALTH QUESTIONS ABOUT YOU
33. Are you currently taking any medication on daily basis?
Yes
No
*
5. Have you ever passed out or nearly passed out DURING or
34. Have you ever had a head injury or concussion? If so,
AFTER exercise?
date of last injury:
6. Have you ever had discomfort, pain, or pressure in your chest
35. Have you ever had numbness, tingling, or weakness in
during exercise?
your arms or legs after being hit or falling?
7. Does your heart race or skip beats during exercise?
36. Do you have headaches with exercise?
8. Has a doctor ever told you that you have (check all that apply):
High Blood Pressure
A heart murmur
37. Have you ever been unable to move your arms or legs
High cholesterol
A heart infection
after being hit or falling?
Kawasaki disease
Other:
9. Has a doctor ever ordered a test for your heart?
38. When exercising in heat, do you have severe muscle
(For ex: ECG/EKG, echocardiogram)
cramps or become ill?
10. Do you get lightheaded or feel more short of breath than
39. Has a doctor told you that you or someone in your family
expected during exercise?
has sickle cell trait or sickle cell disease?
11. Have you ever had an unexplained seizure?
40. Have you had any other blood disorders?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes
No
41. Have you had any problems with your eyes or vision?
12. Has any family member or relative died of heart problems or
had an unexpected sudden death before age 50
42. Do you wear glasses or contact lenses?
(including drowning,
unexplained car accident, or sudden infant death syndrome)?
13. Does anyone in your family have a heart problem?
43. Do you wear protective eyewear, such as goggles or a
face shield?
14. Does anyone in your family have a pacemaker or implanted
44. Do you worry about your weight?
defibrillator?
15. Does anyone in your family have Marfan syndrome,
45. Are you trying to or has any professional recommended
cardiomyopathy, or Long Q-T?
that you try to gain or lose weight?
16. Has anyone in your family had unexplained fainting,
46. Do you limit or carefully control what you eat?
unexplained seizures, or near drowning?
BONE AND JOINT QUESTIONS
Yes
No
47. Do you have any concerns that you would like to discuss
with a doctor?
17. Have you ever had an injury, like a sprain, muscle or ligament
48. What is the date of your last Tdap or Td(tetanus) immunization?
tear, or tendonitis that caused you to miss a practice or game?
(circle type)
Date: ____________
18. Have you had any broken or fractured bones or dislocated
49.Do you have an allergy to medicine, food or stinging
joints?
insects?
19. Have you had a bone or joint injury that required x-rays, MRI,
FEMALES ONLY
CT, surgery, injections, rehabilitation, physical therapy, a
50. Have you ever had a menstrual period?
brace, a cast, or crutches?
20. Have you ever had an x-ray of your neck for atlanto-axial
instability? OR Have you ever been told that you have that
51. Age when you had your first menstrual period? _______
disorder or any neck/spine problem?
21. Have you ever had a stress fracture of a bone?
52. How many periods have you had in the last 12 months?___________
22. Do you regularly use a brace or assistive device?
EXPLAIN “YES” ANSWERS BELOW:
23. Do you currently have a bone, muscle, or joint injury that
bothers you?
#____ » _______________________________________________________
24. Do any of your joints become painful, swollen, feel warm, or
look red?
#____ » _______________________________________________________
25. Do you have a history of juvenile arthritis or connective tissue
#____ » _______________________________________________________
disease?
MEDICAL QUESTIONS
Yes
No
#____ » _______________________________________________________
26. Do you cough, wheeze, or have difficulty breathing during or
after exercise?
#____ » ________________________________________________________
27. Do you have asthma or use asthma medicine (inhaler,
*
nebulizer)
List medications and nutritional supplements you are currently taking here:
28. Were you born without or are you missing a kidney, an eye, a
testicle, spleen or any other organ?
☼►►
Parent/Guardian Signature: __________________________ Date:_________ Athlete’s Signature: _________________________
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