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AAA Medical Forms

The document is a Preparticipation Physical Evaluation form that requires completion before a physical exam, including personal information, medical history, and general health questions. It includes sections for heart health, bone and joint questions, and specific inquiries for females. The form concludes with a physical examination section and a physician's clearance for sports participation.

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Vincent Flieder
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90 views2 pages

AAA Medical Forms

The document is a Preparticipation Physical Evaluation form that requires completion before a physical exam, including personal information, medical history, and general health questions. It includes sections for heart health, bone and joint questions, and specific inquiries for females. The form concludes with a physical examination section and a physician's clearance for sports participation.

Uploaded by

Vincent Flieder
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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■ PREPARTICIPATION PHYSICAL EVALUATION

HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your physical exam.

Name: _____________________________________________ Date of Birth: ___________________ Grade Next Year: ___________

Date of Examination: ___________________ Sex: ___________ Sport(s): ________________________________________________

Have you had COVID-19? Yes No


Have you been immunized for COVID-19? Yes No If yes, you have had: One shot Two shots
List any past and current medical conditions: ________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgeries: _______________________________________________________________________
List any and all medications, over-the-counter medicines, and supplements: _______________________________________________________
List any known allergies: _________________________________________________________________________________________________

GENERAL QUESTIONS MEDICAL QUESTIONS Yes No


(Explain any "Yes" answers at the end of this form. Circle questions 16. Do you cough, wheeze, or have difficulty breathing during or
if you don't know the answer.) Yes No after exercise?
1. Do you have any concerns that you would like to discuss with 17. Are you missing a kidney, an eye, a testicle (males), your
your doctor? spleen, or any other organ?
2. Has a provider ever denied or restricted your participation in 18. Do you have groin or testicle pain or a painful bulge or hernia
sports for any reason? in the groin area?
3. Do you have any ongoing medical issues or recent illness? 19. Do you have any recurring skin rashes or rashes that come and
HEART HEALTH QUESTIONS ABOUT YOU Yes No go, including herpes or MRSA?
4. Have you ever passed out or nearly passed out during or after 20. Have you had a concussion or head injury that caused
exercise? confusion, a prolonged headache, or memory problems?
5. Have you ever had discomfort, pain, tightness, or pressure in 21. Have you ever had numbness, tingling, weakness, or
your chest during exercise? immobility after being hit or falling?
6. Does your heart ever race, flutter in your chest, or skip beats 22. Have you ever become ill while exercising in the heat?
(irregular beats) during exercise? 23. Do you or does someone in your family have sickle cell trait or
7. Has a doctor ever told you that you have a heart problem? disease?
8. Has a doctor ever requested a test for your heart? 24. Have you ever had any problems with your eyes or vision?
(ex.: electrocardiography (ECG) or echocardiography) 25. Do you worry about your weight?
9. Do you get light-headed or feel shorter of breath than your 26. Are you trying or been recommended to gain or lose weight?
friends during exercise? 27. Are you on a special diet or avoid certain types of foods?
10. Have you ever had a seizure? 28. Have you ever had an eating disorder?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No FEMALES ONLY Yes No
11. Has any family member died unexpected before age 35? 29. Have you ever had a menstrual period?
(including drowning or car crash) 30. How old were you when you had your first menstrual period?
12. Does anyone in your family have a genetic heart problem? 31. When was your most recent menstrual period?
(ex.: hypertrophic cardiomyopathy or Marfan syndrome) 32. How many periods have you had in the past 12 months?
13. Has anyone in your family had a pacemaker or an implanted
defibrillator before age 35? Explain any "Yes" answers here:
BONE AND JOINT QUESTIONS Yes No
14. Have you ever had a stress fracture or injury to a bone, muscle,
ligament, or tendon that caused you to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint injury that
bothers you?

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
I also give permission for my child to recieve a physical examination in my absence.

Signature of Student: ______________________________________________________________

Signature of Parent or Guardian: _____________________________________________________ Date: ______________________

© 2019 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.
■ PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name: Date of Birth:

EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □Y □N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insufficiency)
Eyes, ears, nose, and throat
• Pupils equal, hearing

Lymph nodes
Heart*
• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs
Abdomen
Skin
• Herpes simplex virus (HSV), methicillin-resistant Staphylococcus aureus (MRSA), ortinea corporis

Neurological
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder and arm
Elbow and forearm
Wrist, hand, and fingers
Hip and thigh
Knee
Leg and ankle
Foot and toes
Functional
• Double-leg squat test, single-leg squat test, and box drop or step drop test
*
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings

† 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. 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 Provider: Date of Exam:


Address: Phone:
Signature of Physician, APN, PA:

© 2019 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.

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