PREPARTICIPATION PHYSICAL EVALUATION

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

History

Athlete's Name*

First Last

Is the athlete 18 or older?*

Yes
No

Athlete's Date of Birth*

Athlete's Date of Examination*

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.)*

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge*

Not at all
Several days
Over half the days
Nearly every day

Not being able to stop or control worrying*

Not at all
Several days
Over half the days
Nearly every day

Little interest or pleasure in doing things*

Not at all
Several days
Over half the days
Nearly every day

Feeling down, depressed, or hopeless*

Not at all
Several days
Over half the days
Nearly every day

Score

A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes. Automatically calculated - do not edit

General Questions

1. 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 You

4. 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 Family

11. 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 Questions

14. 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 Questions

16. 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, explain

25. 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?*

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*

© 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.

Sports Physical Evaluation

SBHC Sports Physical

PREPARTICIPATION PHYSICAL EVALUATION

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.

History

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

General Questions

Heart Health Questions About You

Heart Health Questions About Your Family

Bone and Joint Questions

Medical Questions