(Explain “Yes” answers at the end of this form.
Circle questions if you don’t know the answer.) 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
HEART HEALTH QUESTIONS ABOUT YOU Yes No
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, utter in your chest,
or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any
8. Has a doctor ever requested a test for your
heart? For example, electrocardiography (ECG)
■ PREPARTICIPATION PHYSICAL EVALUATION
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Date of examination: _______________________________ Sport(s): _____________________________________________________
Sex: M/F __________________________________________
List past and current medical conditions. _____________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (check box next to appropriate number)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
HEART HEALTH QUESTIONS ABOUT YOU
(CONTINUED ) Yes No
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 QUESTIONS ABOUT YOUR FAMILY Yes No
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 syndrome (SQTS),
Brugada syndrome, or catecholaminergic poly-
morphic ventricular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or
an implanted debrillator before age 35?
12_Forms_215-226.indd 217 3/20/19 4:18 PM
Approved for Use Beginning March 2021