PREPARTICIPATION PHYSICAL EVALUATION Note: Complete and sign this form (with your parents if younger than 18) before your appointment.HistoryAthlete's Name* First Last Is the athlete 18 or older?* Yes No Athlete's Date of Birth* MM slash DD slash YYYY Athlete's Date of Examination* MM slash DD slash YYYY Sport(s)* Sex Assigned at Birth* Female Male Intersex How do you identify your gender?* Female Male Intersex List past and current medications.*Have you ever had surgery?* Yes No List all past surgical procedures.*Medicines and Supplements: list all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).*Do you have any allergies?* Yes No Please list all your allergies (ie, medicines, pollens, food, stinging insects.)*General Questions1. Do you have any concerns that you would like to discuss with your provider?* Yes No If yes, explain*2. Has a provider ever denied or restricted your participation in sports for any reason?* Yes No If yes, explain*3. Do you have any ongoing medical issues or recent illness?* Yes No If yes, explain*Heart Health Questions About You4. Have you ever passed out or nearly passed out during or after exercise?* Yes No If yes, explain*5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?* Yes No If yes, explain*6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?* Yes No If yes, explain*7. Has a doctor ever told you that you have any heart problems?* Yes No If yes, explain*8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.* Yes No If yes, explain*9. Do you get light-headed or feel shorter of breath than your friends during exercise?* Yes No If yes, explain*10. Have you ever had a seizure?* Yes No If yes, explain*Heart Health Questions About Your Family11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?* Yes No If yes, explain*12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?* Yes No If yes, explain*13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?* Yes No If yes, explain*Bone and Joint Questions14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?* Yes No If yes, explain*15. Do you have a bone, muscle, ligament, or joint injury that bothers you?* Yes No If yes, explain*Medical Questions16. Do you cough, wheeze, or have difficulty breathing during or after exercise?* Yes No if yes, explain*17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?* Yes No If yes, explain*18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?* Yes No If yes, explain*19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?* Yes No If yes, explain*20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?* Yes No If yes, explain*21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?* Yes No If yes, explain*22. Have you ever become ill while exercising in the heat?* Yes No If yes, explain*23. Do you or does someone in your family have sickle cell trait or disease?* Yes No If yes, explain*24. Have you ever had or do you have any problems with your eyes or vision?* Yes No If yes, explain25. Do you worry about your weight?* Yes No If yes, explain*26. Are you trying to or has anyone recommended that you gain or lose weight?* Yes No If yes, explain*27. Are you on a special diet or do you avoid certain types of foods or food groups?* Yes No If yes, explain*28. Have you ever had an eating disorder?* Yes No If yes, explain*Are you female?* Yes No 29. Have you ever had a menstrual period?* Yes No 30. How old were you when you had your first menstrual period?*31. When was your most recent menstrual period?* MM slash DD slash YYYY 32. How many periods have you had in the past 12 months?*Acknowledgement* I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct. Signature of Athlete* Signature of Parent/Guardian* Date* MM slash DD slash YYYY © 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.
