Sports Physical History

Preparticipation Physical History
Email and email verification
(MM/DD/YYYY)
(MM/DD/YYYY)

Over the last 2 weeks have you experienced any of the following (check all that apply!)

Feeling nervous, anxious, or on edge
Not begin able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

GENERAL QUESTIONS. Explain "Yes" answers.

1. Do you have any concerns that you would like to discuss with your provier?
2. Has a provider ever denied or restricted your participation in sports for any reason?
3. Do you have any ongoing medical issues or recent illness?

HEART HEALTH QUESTIONS ABOUT YOU

4. Have you ever passed out or nearly passed out during or after exercise?
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any heart problems?
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
10. Have you ever had a seizure?

HEART HEALTH QUESITONS 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)?
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 syndreme (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

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?
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?

OTHER MEDICAL QUESTIONS

16. Do you cough, wheeze, or have diffculty breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
18. Do you have a groin or testicle pain or a painful bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
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?
22. Have you ever become ill while exercising in the heat?
23. Do you or does someone in your family have sickle cell trait or disease?
24. Have you ever had or do you have any problems with your eyes or vision?
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended that you gain or lose weight?
27. Are you on a special diet or do you avoid certain types of foods or food groups?
28. Have you ever had an eating disorder?

FOR FEMALES ONLY

29. Have you ever had a menstrual period?
(MM/DD/YYYY)