Fillable Form 2.: PRE-PARTICIPATION PHYSICAL EVALUATION INSTRUCTIONS (City of Oakland)

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Form 2.: PRE-PARTICIPATION PHYSICAL EVALUATION INSTRUCTIONS (City of Oakland)

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Kansas State High School Activities Association
PRE-PARTICIPATION PHYSICAL EVALUATION INSTRUCTIONS
STUDENTS/PARENTS
1.  Complete the History Form (pages 1 & 2) portion PRIOR to your appointment with your healthcare provider.
2. 
Sign the bottom of the History Form (page 2).
3. 
Complete the Shared Emergency Information section on the Medical Eligibility Form (page 4).
4. 
Sign the bottom of the Medical Eligibility Form (page 4) AFTER the pre-participation evaluation is complete and PRIOR to
turning in the completed PPE to the school.
5. 
Review the Student Eligibility Checklist (page 5) AND SIGN the bottom of the page PRIOR to turning in the completed PPE
to the school.
6. 
Review and sign the Concussion and Head Injury Release Form provided by the school.
HEALTHCARE PROVIDERS
1.  Review the History Form (pages 1 & 2) with the student and his/her parent/guardian as part of the pre-participation physical
evaluation.
2. 
Complete the Physical Examination Form (page 3) AND SIGN the bottom of page 3.
3. 
Complete the Medical Eligibility Form (page 4) AND SIGN page 4.
NOTE: Two signatures are required by the healthcare provider!
SCHOOL ADMINISTRATORS
1.  Collect the completed PPE forms with the appropriate signatures on pages 2 – 5.
2. 
Based on your school’s policy, determine who is responsible to review and disseminate the student’s medical information
provided on the form.*
3. 
ProvidecopiesoftheMedicalEligibilityFormtoappropriatestawithsupervisoryresponsibilityofextracurricularactivities
(coaches, sponsors, etc.).
4. 
Collect the required Concussion and Head Injury Release Form signed by the student and parent/guardian.
* Schools are encouraged to have policies in place identifying who has access to a student’s complete private health information
foundonthePPEform.TheMedicalEligibilityFormcanbeusedindependentlytosharewithstawhomaynotneedcomplete
access to the private health information found on the PPE.
The annual history and the physical examination shall not be taken earlier than May 1 preceding the school year for which it is
applicable.TheKSHSAArecommendscompletionofthisevaluationbyathletes/cheerleadersatleastonemonthpriortotherst
practicetoallowtimeforcorrectionofdecienciesandimplementationofconditioningrecommendations.
Kansas State High School Activities Association
PRE-PARTICIPATION PHYSICAL EVALUATION
PPE is required annually and shall not be taken earlier than May 1 preceding the school year for which it is applicable.
HISTORY FORM (Pages 1 & 2 should be lled out by the student and parent/guardian prior to the physical examination)
PPE
Name Sex Age Date of birth
Grade School Sport(s)
Home Address Phone    
Personal physician Parent Email
GENERAL QUESTIONS: YES NO
1. Do you have any concerns that you would like to discuss with your provider?
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?
4. Have you ever spent the night in the hospital?
HEART HEALTH QUESTIONS ABOUT YOU: YES NO
5. Have you ever passed out or nearly passed out during or after exercise?
6. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
7. Does your heart ever race, utter in your chest, or skip beats (irregular beats) during exercise?
8. Has a doctor ever told you that you have any heart problems?
9. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
10. Do you get light-headed or feel shorter of breath than your friends during exercise?
11. Have you ever had a seizure?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY: YES NO
12. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (includ-
ing drowning or unexplained car crash)?
13. 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)?
14. Has anyone in your family had a pacemaker or an implanted debrillator before age 35?
BONE AND JOINT QUESTIONS: YES NO
15. 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?
16. Have you ever had any broken or fractured bones or dislocated joints?
17. Have you ever had an injury that required x-rays, MRI, CT scan, injections or therapy?
18. Have you ever had any injuries or conditions involving your spine (cervical, thoracic, lumbar)?
19. Do you regularly use, or have you ever had an injury that required the use of a brace, crutches, cast, orthotics or other assistive device?
20. Do you have a bone, muscle, ligament, or joint injury that bothers you?
21. Do you have any history of juvenile arthritis, other autoimmune disease or other congenital genetic conditions (e.g., Downs Syndrome or
Dwarsm)?
List past and current medical conditions: _________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures: _____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Medicines and Allergies:
Please list all of the prescription and over-the-counter medicines, inhalers, and supplements (herbal and nutritional) that you are currently taking:
_____________________________________________________________________________________________________________________________________________________________
 No Medications
Do you have any allergies? 
 Yes   No If yes, please identify specic allergy below.
 Medicines ___________________   Pollens ___________________   Food ___________________   Stinging Insects __________________
What was the reaction? ____________________________________________________________________________________________________________________________________________________________
Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.
Rev. 3/2020
1
Kansas State High School Activities Association, 601 SW Commerce Place | PO Box 495 | Topeka, KS 66601 | 785-273-5329
MEDICAL QUESTIONS: YES NO
22. Do you cough, wheeze, or have diculty breathing during or after exercise?
23. Have you ever used an inhaler or taken asthma medicine?
24. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organs?
25. Do you have groin or testicle pain, a bump, a painful bulge or hernia in the groin area?
26. Have you had infectious mononucleosis (mono)?
27. Do you have any recurring skin rashes or skin infection that come and go, including herpes or methicillin-resistant Staphylococcus aureus
(MRSA)?
28. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
If yes, how many?
What is the longest time it took for full recovery?
When were you last released?
29. Do you have headaches with exercise?
30. Have you ever had numbness, tingling, weakness in your arms (including stingers/burners) or legs, or been unable to move your arms or legs
after being hit or falling?
31. Have you ever become ill while exercising in the heat?
32. Do you get frequent muscle cramps when exercising?
33. Do you or does someone in your family have sickle cell trait or disease?
34. Have you ever had or do you have any problems with your eyes or vision?
35. Do you wear protective eyewear, such as goggles or a face shield?
36. Do you worry about your weight?
37. Are you trying to or has anyone recommended that you gain or lose weight?
38. Are you on a special diet or do you avoid certain types of foods or food groups?
39. Have you ever had an eating disorder?
40. How do you currently identify your gender?
 M  F  Other_____________________
41. Over the last 2 weeks, how often have you been bothered by any of the following problems? (check box)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
(A sum of 3 or more is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes)
Patient Health Questionnaire Version 4 (PHQ-4)
FEMALES ONLY: YES NO
42. Have you ever had a menstrual period?
43. If yes, are you experiencing any problems or changes with athletic participation (i.e., irregularity, pain, etc.)?
44. How old were you when you had your rst menstrual period?
45. When was your most recent menstrual period?
46. How many menstrual periods have you had in the past 12 months?
KSHSAA PRE-PARTICIPATION PHYSICAL EVALUATION
NOT AT ALL SEVERAL
DAYS
OVER HALF
THE DAYS
NEARLY
EVERY DAY
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
Explain all Yes answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of student-athlete __________________________________________ Signature of parent/guardian __________________________________________ Date ___________________
Kansas State High School Activities Association, 601 SW Commerce Place | PO Box 495 | Topeka, KS 66601 | 785-273-5329
Adapted from PPE: Preparticipation Physical Evaluation, 5th Edition, © 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 noncom-
mercial, educational purposes with acknowledgment.
Rev. 3/2020
2
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Name Date of birth
Date of recent immunizations: Td Tdap Hep B Varicella HPV Meningococcal
PHYSICAL EXAMINATION FORM
PHYSICIANREMINDERS 
1. Consider additional questions on more sensitive issues
- Do you feel stressed out or under a lot of pressure?
- Do you ever feel sad, hopeless, depressed, or anxious?
- Do you feel safe at your home or residence?
- Haveyouevertriedcigarettes,e-cigarettes,chewingtobacco,snu,ordip?
- Duringthepast30days,didyouusechewingtobacco,snu,ordip?
- Do you drink alcohol or use any other drugs?
- Have you ever taken anabolic steroids or used any other performance
enhancing supplement?
- Have you ever taken any supplements to help you gain or lose weight or
improve your performance?
- Do you wear a seat belt, use a helmet and adhere to safe sex practices?
EXAMINATION
Height Weight Male   Female   BP (reference gender/height/age chart)**** / ( / ) Pulse
Vision R 20/ L 20/ Corrected: Yes 
 No 
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
- Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insuciency)
Eyes/ears/nose/throat
- Pupils equal, Gross Hearing
Lymph nodes
Heart *
- Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Pulses
- Simultaneous femoral and radial pulses
Lungs
Abdomen
Skin
- Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA),
or tinea corporis
Neurological***
Genitourinary (optional-males only)**
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/ngers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
- e.g. double-leg squat test, single-leg squat test, and box drop or step drop test
2. Consider reviewing questions on cardiovascular symptoms (questions 5-14 of History Form).
3. Per Kansas statute, any school athlete who has sustained a concussion shall not return to competition or practice until the athlete is evaluated by a
healthcare provider and the healthcare provider (MD or DO only) provides such athlete a written clearance to return to play or practice.
KSHSAA PRE-PARTICIPATION PHYSICAL EVALUATION
*Considerelectrocardiography(ECG),echocardiography,referraltoacardiologistforabnormalcardiachistoryorexaminationndings,oracombinationofthose. **Consider GU exam if in ap-
propriate medical setting. Having third party present is recommended. ***Considercognitiveevaluationorbaselineneuropsychiatrictestingifasignicanthistoryofconcussion. ****FlynnJT,
Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.
I acknowledge I have reviewed the preceding patient history pages and have performed the above physical examination on the student named on this form.
Name of healthcare provider (print/type) _________________________________________________________________________________________ Date _____________________________
Signature of healthcare provider ___________________________________________________________________________________________________________, MD, DO, DC, PA-C, APRN
(please circle one)
Address _________________________________________________________________________________________________________________ Phone _________________________________________
Healthcare Providers: You must complete the Medical Eligibility Form on the following page
Kansas State High School Activities Association, 601 SW Commerce Place | PO Box 495 | Topeka, KS 66601 | 785-273-5329
Adapted from PPE: Preparticipation Physical Evaluation, 5th Edition, © 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 noncom-
mercial, educational purposes with acknowledgment.
Rev. 3/2020
3
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KSHSAA PRE-PARTICIPATION PHYSICAL EVALUATION
Name _____________________________________________________________________________________________________________________________ Date of birth __________________________________
 Medically eligible for all sports without restriction
 Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of
______________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
 Medically eligible for certain sports
______________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
 Not medically eligible pending further evaluation
 Not medically eligible for any sports
MEDICAL ELIGIBILITY FORM
mercial, educational purposes with acknowledgment.
Recommendations: ________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to
practice and can participate in the sport(s) as outlined on this form, except as indicated above. If conditions arise after the athlete has been cleared for participation, the
physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).
Name of healthcare provider (print or type): ___________________________________________________________________________________________________ Date: ___________________________
Signature of healthcare provider: _________________________________________________________________________________________________________ , MD, DO, DC, or PA-C, APRN
Address: ___________________________________________________________________________________________________________________________________ Phone: ________________________________
SHARED EMERGENCY INFORMATION
Allergies: ___________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Medications: _______________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Other information: _________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Emergency contacts: ______________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
Parent or Guardian Consent
To beeligible for participation ininterscholastic athletics/spirit groups,a student must haveon file with thesuperintendent or principal, asigned statement bya
physician,chiropractor, physician's assistant who has been authorized to perform the examination by a Kansas licensed supervising physician or an advanced practice
registered nurse who has been authorized to perform this examination by a Kansas licensed supervising physician, certifying the student has passed an adequate
physical exami-nationandisphysicallyfittoparticipate(SeeKSHSAAHandbook,Rule7).Acompletehistoryandphysicalexaminationmustbeperformedannually
beforeastudentparticipates in KSHSAA interscholastic athletics/cheerleading.
I do not know of any existing physical or any additional health reasons that would preclude participation in activities. I certify that the answers to the questions in the
HISTORY part of the Preparticipation Physical Examination (PPE), are true and accurate. I approve participation in activities. I hereby authorize release to the KSHSAA,
schoolnurse,certifiedathletictrainer(whetheremployeeorindependentcontractoroftheschool),schooladministrators,coachandmedicalproviderofinformation
contained in this document. Upon written request, I may receive a copy of this document for my own personal health care records.
I acknowledge that there are risks of participating, including the possibility of catastrophic injury. I hereby give my consent for the above student to compete in KSHSAA
approved activities, and to accompany school representatives on school trips and receive emergency medical treatment when necessary. It is understood that neither
the KSHSAA nor the school assumes any responsibility in case of accident. The undersigned agrees to be responsible for the safe return of all equipment issued by the
school to the student.
Signature of parent/guardian _____________________________________________________________________________________________________ Date _________________________________
The parties to this document agree that an electronic signature is intended to make this writing effective and binding and to have the same force and effect as the use of a
manual signature.
Kansas State High School Activities Association, 601 SW Commerce Place | PO Box 495 | Topeka, KS 66601 | 785-273-5329
Adapted from PPE: Preparticipation Physical Evaluation, 5th Edition, © 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 noncom-
Rev. 3/2020
4
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NOTE: Transfer Rule 18 states in part, a student is eligible transfer-wise if:
BEGINNING SEVENTH GRADER—A seventh grader, at the beginning of his or her seventh grade year, is eligible under the Transfer Rule at any school he or she may
choose to attend. In addition, age and academic eligibility requirements must also be met.
BEGINNINGNINTHGRADERSINATHREE-YEARJUNIORHIGHSCHOOL—Sothatninthgradersofathree-yearjuniorhigharetreatedequallytoninthgradersofafour-year
senior high school, a student who has successfully completed the eighth grade of a two-year junior high/middle school, may transfer to the ninth grade of a three-year
junior high school at the beginning of the school year and be eligible immediately under the Transfer Rule. Such a ninth grader must then, as a tenth grader, attend the
feederseniorhighschooloftheirschoolsystem.Shouldtheyattendadierentschoolasatenthgrader,theywouldbeineligibleforeighteenweeks.
ENTERINGHIGHSCHOOLFORTHEFIRSTTIME—AseniorhighschoolstudentiseligibleundertheTransferRuleatanyseniorhighschoolheorshemaychoosetoattend
whenseniorhighisenteredforthersttimeatthebeginningoftheschoolyear.Inaddition,ageandacademiceligibilityrequirementsmustalsobemet.
For Middle/Junior High and Senior High School Students to Retain Eligibility
Schools may have stricter rules than those pertaining to the questions above or listed below. Contact the principal or coach on any matter of eligibility. A student
eligibletoparticipateininterscholasticactivitiesmustbecertiedbytheschoolprincipalasmeetingalleligibilitystandards.
AllKSHSAArulesandregulationsarepublishedintheocialKSHSAA Handbook which is distributed annually to schools and is available at www.kshsaa.org.
Below Are Brief Summaries Of Selected Rules. Please See Your Principal For Complete Information.
Rule 7 Physical Evaluation - Parental Consent—Students shall have passed the attached evaluation and have the written consent of their parents or legal
guardian.
Rule 14 Bona Fide Student—Eligible students shall be a bonadeundergraduatemember of his/her school in good standing.
Rule 15 Enrollment/Attendance—Students must be regularly enrolled and in attendance not later than Monday of the fourth week of the semester in which
they participate.
Rule 16 Semester Requirements—A student shall not have more than two semesters of possible eligibility in grade seven and two semesters in grade eight. A
student shall not have more than eight consecutive semesters of possible eligibility in grades nine through twelve, regardless of whether the ninth grade
is included in junior high or in a senior high school.
NOTE: If a student does not participate or is ineligible due to transfer, scholarship, etc., the semester(s) during that period shall be counted toward the total number of semesters possible.
Rule 17 Age Requirements—Students are eligible if they are not 19 years of age (16, 15 or 14 for junior high or middle school student) on or before August 1 of
the school year in which they compete.
Rule19 UndueInuence—The use of undueinuence by any person to secure or retain a student shall cause ineligibility. If tuition is charged or reduced, it
shall meet the requirements of the KSHSAA.
Rules 20/21 Amateur and Awards Rules—Students are eligible if they have not competed under a false name or for money or merchandise of intrinsic value, and
have observed all other provisions of the Amateur and Awards Rules.
Rule 22 Outside Competition—Students may not engage in outside competition in the same sport during a season in which they are representing their school.
NOTE: Consult the coach, athletic director or principal before participating individually or on a team in any game, training session, contest, or tryout conducted
by an outside organization.
Rule 25 Anti-Fraternity—Students are eligible if they are not members of any fraternity or other organization prohibited by law or by the rules of the KSHSAA.
Rule 26 Anti-Tryout and Private Instruction—Students are eligible if they have not participated in training sessions or tryouts held by colleges or other outside
agencies or organizations in the same sport while a member of a school athletic team.
Rule 30 Seasons of Sport—Students are not eligible for more than four seasons in one sport in a four-year high school, three seasons in a three-year high school
or two seasons in a two-year high school.
Student’s Name _______________________________________________________________________________ (PLEASE PRINT CLEARLY)
For Middle/Junior High and Senior High School Students to Determine Eligibility When Enrolling
If a negative response is given to any of the following questions, this enrollee should contact his/her administrator in charge of evaluating eligibility. This should be
donebeforethestudentisallowedtoattendhis/herrstclassandpriortotherstactivitypractice.Ifquestionsstillexist,theschooladministratorshouldtelephone
theKSHSAAforanaldeterminationofeligibility. (Schools shall process a Certicate of Transfer Form T-E on all transfer students.)
YES  NO
1. Areyouabonadestudentingood standing in school? (If there is a question, your principal will make that determination.)
2.
Did you passatleastvenewsubjects(thosenotpreviouslypassed) last semester? (The KSHSAA has a minimum regulation which requires you
to pass at least ve subjects of unit weight in your last semester of attendance.)
3.
Are you planning to enrollinatleastvenewsubjects(thosenotpreviouslypassed) of unit weight this coming semester?
(The KSHSAA has a minimum regulation which requires you to enroll and be in attendance in at least ve subjects of unit weight.)
4.
Did you attend this school or a feeder school in your district last semester? (If the answer is “no” to this question, please answer Sections a and b.)
a. Doyouresidewithyourparents?
b. Ifyouresidewithyourparents,havetheymadeapermanentandbonademoveintoyourschool’sattendancecenter?
Rev. 3/2020
5
ATTENTION PARENTS AND STUDENTS: KSHSAA ELIGIBILITY CHECKLIST
The above named student and I have read the KSHSAA Eligibility Checklist and how to retain eligibility information listed in this form. The student/parent
authorizes the school to release to the KSHSAA student records and other pertinent documents and information for the purpose of determining student
eligibility. The student/parent also authorizes the school and the KSHSAA to publish the name and picture of student as a result of participating in or attending
extra-curricular activities, school events and KSHSAA activities or events.
Signature of parent/guardian _____________________________________________________________________________________________________ Date _________________________________
Signature of student __________________________________________________________________ Birth Date________________ Grade_________ Date _________________________________
The parties to this document agree that an electronic signature is intended to make this writing eective and binding and to have the same force and eect as the use of a manual
signature.
Kansas State High School Activities Association, 601 SW Commerce Place | PO Box 495 | Topeka, KS 66601 | 785-273-5329
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Form 2.: PRE-PARTICIPATION PHYSICAL EVALUATION INSTRUCTIONS (City of Oakland)

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Completed 29 July 2021

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