~
!Revised February
20171
~he
prc~participation physical examination
is
not a substitute for a thorough annual examination by a student's primary care physician
rl
_P_a_g_e_2_o_f_4~
PART
II
- -
MEDICAL
HISTORY-Explain
"Yes"
answers
below
This form
must
be completed
and
signed,
prior
to
the
physical examination, for review by examining
practitioner.
Exolain
"Yes"
answers below with
number
of
the
auestion. Circle auestions vou
don't
know
the
answers
to.
GENERAL
MEDICAL
HISTORY
Yes
No
MEDICAL
QUESTIONS
{cont)
Yes
No
1.
Has a doctor ever denied
or
restricted your participation in
□ □
29. Do you have groin pain
or
a painful bulge
or
hernia in
□ □
sports
for
any reason? the groin area?
2. Do you currently have an ongoing medical condition?
Ifso,
Please identify: D
Asthma
D Anemia D Diabetes
□
□
30. Have you had mononucleosis (mono) within the last
□
□
D Infections D Other: month?
3. Have you ever spent the night in the hospital?
□ □
31. Do you have any rashes, pressure sores,
or
other skin
□ □
problems?
4. Have you ever had surgery?
□ □
32. Have you ever had a heroes
or
MR.SA skin infection?
□ □
HEART
HEALTH
QUESTIONS
ABOUT
YOU
Yes
No
33. Are you currently taking
any
medication on daily basis?
□•
□
5. Have you ever passed out
or
nearly passed out DURING
or
□ □
34. Have you ever had a head injury
or
concussion?
If
so,
□ □
AFTER exercise?
date
of
last injury:
6.
Have you ever had discomfort, pain, or pressure in your chest
□
□
35. Have you ever had numbness, tingling,
or
weakness in
□ □
during exercise? your
anns
or
legs after being hit
or
falling?
7.
Does your heart race
or
skip beats during exercise?
□
□
36.
Do you have headaches with exercise?
□ □
8.
Has a doctor ever told you that you have (check all that apply):
OHigh
I3lood Pressure
DA
heart murmur
□ □
37.
Have you ever been unable to move your arms
or
legs
□ □
□
High
cholesterol
DA
heart infection
after being hit
or
falling?
□
Kawasaki
disease
□
Other:
9.
Has a doctor ever ordered a test for your heart?
□ □
38.
Wheu-
exercising in heat, do you have severe muscle
□ □
(For ex: ECG/EKG, echocardiogram)
cramps
or
become ill?
10.
Do you get lightheaded
or
feel more short
of
breath than
39.
Has a doctor told you that you or someone
in
your family
□ □
expected during exercise?
□
□
has sickle cell trait or sickle cell disease?
11.
Have you ever had an unexplained seizure?
□ □
40. Have you had any other blood disorders?
□ □
HEART HEALTH QUESTIONS ABOUT
YOUR
FAlVIILY
Yes
No
41.
Have you had any problems with your eyes
or
vision?
□ □
12.
Has any family member
or
relative died
of
heart problems
or
had an unexpected sudden death before age 50
(including
drowning,
□ □
42. Do you wear glasses
or
contact lenses?
□ □
unexnlained
car
accident,
or
sudden
infant
death
svndromc}?
13.
Does anyone in your family have a heart problem?
□ □
43.
Do you wear protective eyewear, such as goggles
or
a
□
□
face shield?
14.
Does anyone
in
your family have a pacemaker
or
implanted
□ □
defibrillator?
44.
Do you worry about your weight?
□ □
15.
Docs anyone in your family have Marfan syndrome,
□
□
45.
Are you trying to
or
has any professional recommended
□
□
cardiomyopathy,
or
Long
Q-T?
that you try to gain
or
lose weight?
16.
Has anyone
in
your family had unexplained fainting,
□ □
unexplained seizures,
or
near
drowning?
46.
Do you limit
or
carefully control what you eat?
□ □
BONE
AND
JOINT
QUESTIONS
Yes
No
47.
Do you have any concerns that you would like to discuss
□
□
with a doctor?
17.
Have you ever had an injury, like a sprain, muscle
or
ligament
□
□
48. What is the date
of
your last Tdap or Td(tetanus) immunization?
tear,
or
tendonitis that caused you to miss a practice
or
game?
( circle type) Date:
18.
Have you had any broken
or
fractured bones
or
dislocated
□ □
49.Do you have an allergy to medicine, food
or
stinging
joints? insects?
□ □
19.
Have you had a bone
or
joint
injury that required x-rays, MRI, FEMALES ONLY
CT, surgery, injections, rehabilitation, physical therapy, a
□
□
50. Have you ever had a menstrual period?
□ □
brace, a cast,
or
crutches?
20.
Have you ever had
an
x-ray
of
your neck for atlanto-axial
instability?
OR
Have you ever been told that you have that
□ □
51.
Age when you had your first menstrual period?
___
disorder
or
anv neck/soine oroblem?
21.
Have you ever had a stress fracture
of
a bone?
□
□
52.
How many periods have you had in the last 12 months?
22.
Do you regularly use a brace
or
assistive device?
□
□
EXPLAIN
"YES"
ANSWERS
BELOW:
23.
Do you currently have a bone, muscle,
or
joint
injury that
□ □
bothers you?
#_
»
24. Do any
of
your joints become painful, swollen, feel wam1,
or
look red?
□ □
#_
»
25. Do you have a history
of
juvenile arthritis
or
connective tissue
□ □
disease?
#_
»
MEDICAL
QUESTIONS
Yes
No
26. Do you cough, wheeze,
or
have difficulty breathing during
or
#_
»
after exercise?
□ □
#
__
»
27.
Do you have asthma
or
use asthma medicine (inhaler,
□ □
nebulizer)
*List medications and nutritional supplements
you
arc currently taking here:
28. Were you born without
or
are you missing a kidney, an eye, a
testicle, spleen
or
any other organ?
□ □
i)
► ►
Parent/Guardian
Signature:
____________
Date:
___
_ Athlete's Signature:
