Instructions for Completing the NCHSAA Student-Athlete
Preparticipation Physical Evaluation (PPE)
In order to be medically eligible for participation in practice or in interscholastic athletic
contests, a student must have a completed NCHSAA PPE and submit it to the school. The
PPE is four (4) pages in length and includes the History Form, the Physical Examination
Form, and the Medical Eligibility Form.
The PPE History Form (pages 1-2) is completed and signed by the parent or legal
custodian on behalf of the student-athlete. The completed and signed PPE History Form
must then be presented to the examining Licensed Medical Professional (LMP)
(physician licensed to practice medicine (MD/DO), nurse practitioner or physician
assistant) for review when they fill out the Physical Examination Form.
The completed PPE Physical Examination Form (page 3) is signed and dated by the LMP
who performed the examination. The physical examination builds on information
obtained in the medical history.
The PPE Medical Eligibility Form (page 4), which is also signed and dated by the LMP,
indicates the student-athlete is either medically eligible or not medically eligible for
sports participation.
Student-Athlete COVID Questionnaire
Student-Athlete’s Name: __________________________________________________
Date of Birth: ____________________________ Age: __________________________
COVID RELATED QUESTIONS ABOUT THE STUDENT-ATHLETE
YES
NO
NA
1. Since January 1, 2020 have you been told that you have
had a positive test for COVID-19, OR have you been told by
a medical professional, your school, or local health
department that you have had to quarantine (stay home)
due to concern that you had COVID-19 symptoms?
2. If the answer to 1 was “Yes”, has the required Return to
Play Form: COVID-19 Infection Medical Clearance Releasing
The Student-Athlete to Resume Full Participation in
Athletics been completed?
3. Have you been fully vaccinated against COVID?
GENERAL QUESTIONS
(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
recent illness?
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
heart problems?
8. Has a doctor ever requested a test for your
heart? For example, electrocardiography (ECG)
or echocardiography.
PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM
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 debrillator before age 35?
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BONE AND JOINT QUESTIONS Yes No
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?
MEDICAL QUESTIONS Yes No
16. Do you cough, wheeze, or have difculty
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 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 prob-
lems with your eyes or vision?
MEDICAL QUESTIONS (CONTINUED ) Yes No
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?
FEMALES ONLY Yes No
29. Have you ever had a menstrual period?
30. How old were you when you had your rst
menstrual period?
31. When was your most recent menstrual period?
32. How many periods have you had in the past 12
months?
Explain “Yes” answers here.
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I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete
and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: __________________________________________________________________________________________
Date: ________________________________________________________
© 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 noncommercial, educa-
tional purposes with acknowledgment.
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PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________ Date of birth: ____________________________
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, snuff, or dip?
During the past 30 days, did you use chewing tobacco, snuff, 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 use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: Y N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity,
myopia, mitral valve prolapse [MVP], and aortic insufciency)
Eyes, ears, nose, and throat
Pupils equal
Hearing
Lymph nodes
Heart
a
Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs
Abdomen
Skin
Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or
tinea corporis
Neurological
MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS
Neck
Back
Shoulder and arm
Elbow and forearm
Wrist, hand, and ngers
Hip and thigh
Knee
Leg and ankle
Foot and toes
Functional
Double-leg squat test, single-leg squat test, and box drop or step drop test
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination ndings, or a combi-
nation of those.
Name of health care professional (print or type): ___________________________________________________ Date: ___________________
Address: ________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
© 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 noncommercial, educa-
tional purposes with acknowledgment.
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Approved for Use Beginning March 2021
PREPARTICIPATION PHYSICAL EVALUATION
MEDICAL ELIGIBILITY FORM
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
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. A copy of the physical
examination ndings are on record in my ofce and can be made available to the school at the request of the parents. 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 health care professional (print or type): __________________________________________ Date: ____________________________
Address: _________________________________________________________________________ Phone: ___________________________
Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA
SHARED EMERGENCY INFORMATION
Allergies: ____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medications: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other information: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Emergency contacts: ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
© 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 noncommercial, educa-
tional purposes with acknowledgment.
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Approved for Use Beginning March 2021