PREPARTICIPATION
PHYSICAL EVALUATION -- MEDICAL HISTORY
2017
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These
questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student's Name: (print) Sex Age Date of Birth
Address Phone
Grade
Sc
hoo
l
Pers
on
al
Physician Phone
In case of emergency, contact:
Name Relationship Phone (H) (W)
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League
nor the school assumes any responsibility in case an accident occurs.
If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and
consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the
school and any school or hospital representative from any claim by any person on account of such care and treatment of said studen
t.
If, between this date and the beginning of athletic competition, any illness or injury should occur that may limit this student's participation, I agree to notify
the
school
authorities of such
illness or injury.
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could
subject the student in question to penalties determined by the UIL
Student
Signature:
Parent/Guardian
Signature:
Date:
Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician
assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches.
THIS FORM MUST BE ON FILE PRIOR TO
PARTICIPATION IN ANY PRACTICE
, SCRIMMAGE OR CONTEST BEFORE, DURING OR AFTER
SCHOOL.
For School Use Only:
This
Medical
History
Form
was
reviewed
by:
Printed
Name
Date
Signature
1.
Have you had a medical illness or injury since your last check
Yes
!
No
!
13.
Have you ever gotten unexpectedly short of breath with
Yes
!
2.
up or sports physical?
Have you been hospitalized overnight in the past year?
!
!
exercise?
Do you have asthma?
!
Have you ever had surgery?
!
!
Do you have seasonal allergies that require medical treatment?
!
3.
Have you ever had prior testing for the heart ordered by a
physician?
!
!
14.
Do you use any special protective or corrective equipment or
devices that aren't usua
lly used for your sport or position (for
!
Have you ever passed out during or after exercise?
Have you ever had chest pain during or after exercise?
!
!
!
!
example, knee brace, special neck roll, foot orthotics, retainer
on your teeth, hearing aid)?
Do you get tired more quickly than your friends do during
exercise?
!
!
15. Have you ever had a sprain, strain, or swelling after injury?
Have you broken o
r fractured any bones or dislocated any
!
!
Have you ever had racing of your heart or skipped heartbeats?
!
!
joints?
Have you had high blood pressure or high cholesterol?
!
!
Have you had any other problems with pain or swelling in
!
Have you ever been told you have a heart murmur?
!
!
muscles, tendons, bones, or joints?
Has any family member or relative died of heart problems or of
sudden unexpected death before age 50?
!
!
If yes, check appropriate box and explain below:
Has any family member been diagnosed with enlarged heart,
!
!
! Head ! Elbow ! Hip
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long
!
!
!
N
eck ! Forearm ! Thigh
QT syndrome or other ion channelpathy (Brugada syndrome,
! Back ! Wrist ! Knee
etc), Marfan's syndrome, or abnormal heart rhythm?
! Chest ! Hand ! Shin/Calf
Have you had a severe viral infection (for example,
!
!
! Shoulder ! Finger ! Ankle
myocarditis or mononucleosis) within the last month?
! Upper Arm ! Foot
Has a physician ever denied or restricted your participation in
sports for any heart problems?
!
!
16.
17.
Do you want to weigh more or less than you d
o now?
Do you feel stressed out?
!
!
4.
4
.
Have you ever had a head injury or concussion?
!
!
18.
Have you ever been diagnosed with or treated for sickle cell
!
Have you ever been knocked out, become unconscious, or lost
your memory?
!
!
trait or sickle cell disease?
Females Only
If yes, how many times? __________
When was your last concussion? __________
19. When was your first menstrual period?
_____________
How severe was each one? (Explain below)
Have you ever had a seizure?
!
!
Do you have frequent or severe headaches?
!
!
!
!
Have you ever had numbness or tingling in your arms, hands,
legs or feet?
!
!
When was your most recent menstrual period?
_____________
How
much time do you usually have from the start of one period to the start of
another?
_____________
How many periods have you had in the last year? _____________
What was the longest time between periods in the last year? _____________
Have you ever had a stinger, burner, or pinched nerve?
!
!
5.
Are you missing any paired organs?
!
!
6.
Are you under a doctor’s care?
!
!
7.
Are you currently taking any prescription or non-prescription
(over-the-count
er) medication or pills or using an inhaler?
!
!
8.
Do you have any allergies (for example, to pollen, medicine,
food, or stinging inse
cts)?
!
!
9.
Have you ever been dizzy during or after exercise?
!
!
10.
Do you have any current skin problems (for example, itching,
rashes, acne, warts, fungus, or blisters)?
!
!
11.
Have you ever become ill from exercising in the heat?
!
!
12.
Have you had any problems with your eyes or vision?
!
!
Explain “Yes” answers in the box below**. Circle questions you don’t know the answers to.
An individual answering in the affirmative to any question relating to a possible cardiovascular health
issue (question three above), as identified on the form, should be restricted from further participation
pr
unt
a
i
c
l
t
t
iti
he
o
i
ne
ndi
r.
vidual is examined and cleared by a physician, physician assistant, chiropractor, or nurse
**EXPLAIN ‘YES’ ANSWERS IN THE BOX BELOW (attach another sheet if necessary):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________
Males Only
20. Do you have two testicles?
_____________
21
. Do you have any testicular swelling or masses? _____________
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signature
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Lymph
Heart-Auscultation of the heart
the supine
Heart-Auscultation of the heart
the standing
Heart-Lower extremity
Genitalia (males
Marfan’s stigmata
pectus excavatum,
hypermobility,
PREPARTICIPATION
PHYSICAL EVALUATION -- PHYSICAL
E
XAMINATION
Student's Name
_________________________________
Sex _______ Age _______ Date of Birth
_________________________
Height ______ Weight________ % Body fat (optional) ________ Pulse __________ BP____/____ (____/____,
____/____)
brachial blood pressure while
sitti
ng
Vision: R 20/______ L 20/___ Corrected:
!
Y
!
N Pupils:
!
Equal
!
Unequal
As a minimum requirement, this Physical Examination Form must be completed prior to junior high athletic participation
and
again prior to first and third years of high school athletic participation. It must be completed if there are yes answers to
specific
questions on the student's MEDICAL HISTORY FORM on the reverse side. * Local district policy may require an annual
physical
exam.
NORMAL ABNORMAL FINDING
S
INITIALS*
MUSCULOSKELETAL
*station-based examination
only
CLEARANCE
!
Cleared
! Cleared after completing evaluation/rehabilitation for:
__________________________________________________________
_________________________________________________________________________________________________________
! Not cleared
for:_________________________________________Reason:
_________________________________________
Recommendations:
_________________________________________________________________________________________
_________________________________________________________________________________________________________
The following information must be filled in and signed by either a Physician, a Physician Assistant licensed by a State Board
of
Physician Assistant Examiners, a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse
Examiners,
or a Doctor of Chiropractic. Examination forms signed by any other health care practitioner, will not be
accepted.
Name (print/type)
__________________________________________ D
ate of Examination: ______________________________
Address: _______________________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________________________
Signature: _____________________________________________________________________________________________
Must be completed before a student participates in any practice, before, during or after school, (both in-season and out-of-season) or
games/matches.
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signature
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