Participation Physical History Preparticipation Physical History 2010 Email to send my copy Confirm Email to send my copy Email and email verification Name * DOB * (MM/DD/YYYY) Date of Exam (MM/DD/YYYY) Sport(s) * Sex * Male Female Age * Grade * School * Medicines and Allergies Medicines (List prescriptions or over the counter medications, supplements that you are taking.) Do you have allergies? Yes No Are you allergic to any of the following? Medicines Pollens Food Stinging Insects GENERAL QUESTIONS. Explain "Yes" answers. 1. Has a provider ever denied or restricted your participation in sports for any reason? Yes No 2. Do you have any ongoing medical? If so, please identify below: Asthma Anemia Diabetes Infections OtherOther 2. Yes 3. Have you ever spent the night in the hospital? Yes No 4. Have you ever had surgery? Yes No HEART HEALTH QUESTIONS ABOUT YOU 5. Have you ever passed out or nearly passed out During or After exercise? Yes No 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Yes No 7. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? Yes No 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply. High blood pressure High cholesterol Kawasaki disease A heart murmur A heart infection OtherOther 9. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography. Yes No 10. Do you get light-headed or feel shorter of breath than your friends during exercise? Yes No 11. Have you ever had an unexplained seizure? Yes No 12. Do you get more tired or short of breath more quickly than your friends during exercise? Yes No HEART HEALTH QUESITONS ABOUT YOUR FAMILY 13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 years (including drowning, unexplained car crash, or sudden infant death syndrome)? Yes No 14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia? Yes No 15. Has anyone in your family have a heart problem, pacemaker, or implanted defibrillator? Yes No 16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? Yes No BONE AND JOINT QUESTIONS 17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? Yes No 18. Have you ever had any broken or fractured bones or dislocated joints? Yes No 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? Yes No 20. Have you ever had a stress fracture? Yes No 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) Yes No 22. Do you regularly use a brace, orthotics, or other assistive device? Yes No 23. Do you have a bone, muscle, or joint injury that bothers you? Yes No 24. Do any of your joints become painful, swollen, feel warm, or look red? Yes No 25. Do you have any history of juvenile arthritis or connective tissue disease? Yes No MEDICAL QUESTIONS 26. Do you cough, wheeze, or have diffculty breathing during or after exercise? Yes No 27. Have you ever used an inhaler or taken asthma medicine? Yes No 28. Is there anyone in your family who has asthma? Yes No 29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? Yes No 30. Do you have groin pain or a painful bulge or hernia in the groin area? Yes No 31. Have you had infectious mononucleosis (mono) within the last month? Yes No 32. Do you have any rashes, pressure sores, or other skin problems? Yes No 33. Have you had a herpes or MRSA skin infection? Yes No 34. Have you ever had a head injury or concussion? Yes No 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? Yes No 36. Do you have a history of seizure disorder? Yes No 37. Do you have headaches with exercise? Yes No 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? Yes No 39. Have you ever been unable to move your arms or legs after being hit or falling? Yes No 40. Have you ever become ill while exercising in the heat? Yes No 41. Do you get frequent muscle cramps when exercising? Yes No 42. Do you or someone in your family have sickle cell trait or disease? Yes No 43. Have you had any problems with your eyes or vision? Yes No 44. Have you had any eye injuries? Yes No 45. Do you wear glasses or contact lenses? Yes No 46. Do you wear protective eyewear, such as goggles or a face shield? Yes No 47. Do you worry about your weight? Yes No 48. Are you trying to or has anyone recommended that you gain or lose weight? Yes No 49. Are you on a special diet or do you avoid certain types of foods? Yes No 50. Have you ever had an eating disorder? Yes No 51. Do you have any concerns that you would like to discuss with a doctor? Yes No FOR FEMALES ONLY 52. Have you ever had a menstrual period? Yes No 53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain all Yes answers Briefly, explain all "Yes" answers here (256 character maximum). Signature of athlete Clear Signature of parent or guardian Clear Date * (MM/DD/YYYY) If you are human, leave this field blank. Submit
