■ Preparticipation Physical Evaluation

HISTORY FORM
(Note:This formis tobefilledoutbythepatientandparentpriortoseeingthephysician.Thephysicianshouldkeep a copy of this forminthechart.)

Date of Exam
Name Date of birth
Sex Age Grade School Sport(s)

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?  Yes 

No Ifyes,pleaseidentifyspecific allergy below.
 Medicines  Pollens  Food  Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No
1. Hasadoctoreverdeniedorrestricted yourparticipationinsportsfor 26. Do you cough, wheeze, or have difficulty breathing during or
any reason? after exercise?
2. Do you have any ongoing medical conditions? If so, please identify 27. Have you ever used an inhaler or taken asthma medicine?
below:  Asthma  Anemia  Diabetes  Infections 28. Isthereanyoneinyourfamilywhohasasthma?
Other: 29. Wereyou born without or are you missing a kidney,an eye,a testicle
3. Have youeverspent the nightin thehospital? (males), your spleen, or any other organ?
4. Have you ever had surgery? 30. Do you have groinpain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or 32. Do you have any rashes, pressure sores, or other skin problems?
AFTER exercise? 33. Have you had a herpes or MRSA skin infection?
6. Have you ever had discomfort, pain, tightness, or pressure in your 34. Have you ever had a head injury or concussion?
chest during exercise?
35. Haveyouever had a hitor blow to thehead thatcaused confusion,
7. Does your heart ever race or skip beats (irregular beats) during exercise? prolonged headache, or memory problems?
8. Has a doctor ever told you that you have any heart problems? If so, 36. Do you have a history of seizure disorder?
check all that apply:
 Highbloodpressure  A heart murmur 37. Do you have headaches with exercise?
 High cholesterol  A heart infection 38. Have you ever had numbness, tingling, or weakness in your arms or
 Kawasaki disease Other: legsafterbeing hit or falling?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, 39. Have youeverbeenunableto moveyourarms orlegsafterbeing hit
echocardiogram) or falling?
10. Do you get lightheaded or feel more short of breath than expected 40. Have you ever become ill while exercising in the heat?
duringexercise? 41. Do you get frequent muscle cramps when exercising?
11. Have you ever had an unexplained seizure? 42. Doyou orsomeone inyourfamilyhavesicklecell trait or disease?
12. Do you get more tired or short ofbreath more quickly than your friends 43. Have you had any problems with your eyes or vision?
duringexercise?
44. Have you had any eye injuries?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
45. Do you wear glasses or contact lenses?
13. Has any familymemberor relative diedofheart problems or hadan
46. Do you wear protective eyewear, such as goggles or a face shield?
unexpected or unexplained sudden death before age 50 (including
drowning, unexplained car accident, or sudden infant death syndrome)? 47. Do you worry about your weight?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan 48. Areyoutrying toorhasanyone recommended thatyougainor
syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT lose weight?
syndrome, short QT syndrome, Brugada syndrome,or catecholaminergic 49. Are you on aspecial diet or do youavoid certain typesoffoods?
polymorphic ventricular tachycardia?
50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator? 51. Doyou have any concerns that you wouldlike to discuss with a doctor?

16. Has anyone in your family had unexplained fainting, unexplained FEMALES ONLY
seizures, or near drowning? 52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS Yes No 53. How oldwereyouwhenyouhadyour first menstrualperiod?
17. Have youeverhadaninjurytoabone,muscle,ligament,ortendon 54. How manyperiodshaveyouhadin thelast 12months?
thatcausedyouto missapracticeora game?
Explain “yes” answers here
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan,
injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Haveyou everbeen told thatyouhaveorhave you hadanx-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do youhave abone,muscle,orjointinjury that bothers you?
24. Doany ofyourjointsbecomepainful,swollen,feelwarm,orlookred?
25. Do you have any history of juvenile arthritis or connective tissue disease?

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete Signature of parent/guardian Date

©2010 American Academy of Family Physicians,American Academy of Pediatrics,American College of Sports Medicine,American Medical Society for Sports Medicine,American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503 9-2681/0410
■■■PreparticipationPhysicalEvaluation
THEATHLETEWITH PECIALNEED :
UPPLEMENTALHI TORYFORM
Date of Exam ___________________________________________________________________________________________________________________
Name __________________________________________________________________________________ Date of birth __________________________
Sex _______ Age __________ Grade _____________ School _____________________________ Sport s) __________________________________

1. Type of disability
2. Date of disability
3. Classifcation if available)
4. Cause of disability birth, disease, accident/trauma, other)
5. List the sports you are interested in playing
Yes No
6. Do you regularly use a brace, assistive device, or prosthetic?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or any other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysrefexia?
14. Have you ever been diagnosed with a heat-related hyperthermia) or cold-related hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “yes” answers here

Please indicate if you have ever had any of the followin .

Yes No
Atlantoaxial instability
X-ray evaluation for atlantoaxial instability
Dislocated joints more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Diffculty controlling bowel
Diffculty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifda
Latex allergy

Explain “yes” answers here

I hereby state that, to the best of my knowled e, my answers to the above questions are complete and correct.

Signature of athlete __________________________________________ Signature of parent/guardian __________________________________________________________ Date _____________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Colle e of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is ranted to reprint for noncommercial, educational purposes with acknowled ment.
■■■PreparticipationPhysicalEvaluation
PHYSICA EXAMINATIONFORM
Name __________________________________________________________________________________ Date of birth __________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues
Do you feel stressed out or under a lot of pressure?
Do you ever feel sad, hopeless, depressed, or anxious?
Do you feel safe at your home or residence?
Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
During the past 30 days, did you use chewing tobacco, snuff, or dip?
Do you drink alcohol or use any other drugs?
Have you ever taken anabolic steroids or used any other performance supplement?
Have you ever taken any supplements to help you gain or lose weight or improve your performance?
Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION
Height Weight  Male  Female
BP / ( / ) Pulse Vision R 20/ L 20/ Corrected  Y  N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insuffciency)
Eyes/ears/nose/throat
Pupils equal
Hearing
Lymph nodes
Heart a
Murmurs (auscultation standing, supine, +/- Valsalva)
Location of point of maximal impulse (PMI)
Pulses
Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
HSV, lesions suggestive of MRSA, tinea corporis
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fngers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
Duck-walk, single leg hop
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
a

Consider GU exam if in private setting. Having third party present is recommended.

b

Consider cognitive evaluation or baseline neuropsychiatric testing if a history of signifcant concussion.

c

 Cleared for all sports without restriction

 Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________________
____________________________________________________________________________________________________________________________________________
 Not cleared
 Pending further evaluation
 For any sports
 For certain sports _____________________________________________________________________________________________________________________
Reason ___________________________________________________________________________________________________________________________
Recommendations _________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and
participate in the sport s) as outlined above. A copy of the physical exam is on record in my offce and can be made available to the school at the request of the parents. If condi-
tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely
explained to the athlete and parents/guardians).

Name of physician (print/type) _____________________________________________________________________________________________________ Date ________________

Address ___________________________________________________________________________________________________________ Phone _________________________
Signature of physician _______________________________________________________________________________________________________________________, MD or DO

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Colle e of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is ranted to reprint for noncommercial, educational purposes with acknowled ment.
HE0503 9-2681/0410
■■■PreparticipationPhysicalEvaluation
CLEARANCEF RM
Name _______________________________________________________ Sex  M  F Age _________________ Date of birth _________________

 Cleared for all s orts without restriction

 Cleared for all s orts without restriction with recommendations for further evaluation or treatment for _______________________________________________

___________________________________________________________________________________________________________________________

 Not cleared

 Pending further evaluation

 For any s orts

 For certain s orts _____________________________________________________________________________________________________

Reason ___________________________________________________________________________________________________________

Recommendations _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent
clinical contraindications to practice and participate in the sport s) as outlined above. A copy of the physical exam is on record in my offce
and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation,
the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete
and parents/guardians).

Name of hysician ( rint/ty e) ___________________________________________________________________________________ Date ________________

Address _________________________________________________________________________________________ Phone _________________________

Signature of hysician _____________________________________________________________________________________________________, MD or DO

EMERGENCY INFORMATION

Allergies ______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________
Other information _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American Colle e of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is ranted to reprint for noncommercial, educational purposes with acknowled ment.