Pre-Participation Physical Evaluation · BONE AND JOINT QUEITIOfiS Ylll No 53. How old were you...
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• PREPARTICIPATION PHYSICAL EVALUATION HISTORY FORM (Note: This form Is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form In the chart.) Date of Exam ---------------- ------ - - ------------------- Name Date of birth _______ _ _ Sex Age Grade _____ Sport(s) School ----------- Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking Do you have any allergies? DYes D No If yes, please identify specific allergy below. D Medicines D Pollens D Food D Stinging Insects Explain "Yes" answers below. Cln:le questions you don't know the answers to. GENERAL ClUESTIONI Ylll No MEDICAL QUESTIONS Yll No 1. Has a doctor ever denied or restr1cted your participation In sports for 26. Do you cough, wheeze, or have difficulty breathing or any reason? alter exercise? 2 Do you have any ongoing medical condiUons? n so. please Identity 27. Have you ever used an Inhaler or taken asthma medicine? below: D Asthma D Anemia D Diabetes D Infections 28. Is there anyone In your family who has asthma? Other: 29. Were you born without or are you missing a Kidney, an eye, atesHcle 3. Have you ever span! the night in the hospital? (males), your spleen, or any other organ? 4. Have you ever had surgery? 30. Do you have groin pain or apalnlul bulge or hernia In the groin area? HEART HEAUif CiUEmOii$ UOIIf YOU Y• No 31. Have you had Infectious mononucleosis (mono) within lhelast month? 5. Have you ever passed out or passed out DURING or 32. Do you have. any rashes, pressure sores, or other skin problems? AFTER exercise? 33. Have you had aherpes or MRSA skin lnfectlon? 6. Have you ever had discomloo, pain, tightness, or pressure In your 34. Have you ever had ahead Injury or concussion? chest during exercise? 35. Have you ever had ahit or blow to the head that caused confusion, 7. Does your heart ever mea or skip beats (Irregular beats) exercise? prolonged headache, or memory problems? 8. Has a doctor ever told you that you have any heart problems? Hso, 36. Do you have ahistory of seizure disorder? check aY that apply: 37. Do you have headaches with exercise? D High blood pressure D Aheart murmur D High chOlesterol D Aheart Infection 38. Have you ever had numbness, tingling, or weakness In your arms or D Kawasaki disease other: legs after being hit or falling? 9. Has a doctor ever ordered atest lor your heart? (For example, ECGIEKG, 39. Have you ever been unable to move your arms or lags after being hit echocardlogram) or falling? 10. Do you get llghtheaded or feel more short or breath than expected 40. Have you ever become ill while exercising In the heat? during exercise? 41. Do you get frequent muscle cramps when exercising? 11. Have you ever had an unexplained seizure? 42. Do you or someone In your family have sickle cell trait or disease? 12. Do you get more Urad or short ol breath more quicKly than your friends 43. Have you had any problems with your ayes or vision? during exercise? 44. Have you had any eye HEART HEAUH QtiEI110NI ABOUT YOUR FAIIILY Ylll No 45. Co )IIl ii wear gi1!8£8S nr conl acr lerl!llls? 13. Has any family member or relative died of heart problems or had an 46. Do you wear protective eyewear, such as goggles or aface shield? unexpected or unexplained sudden death before age 50 (Including drowning, unexplained car accident, or sudden infant death syndrome)? 47 Do you worry about your weight? 14. Does anyone In your family have hypertrophic cardiomyopathy, Marian 48. Are you trying to or has anyone recommended that you gain or syndrome, arrhythmogenlc rlgtrt cardiomyopathy, long QT lose weight? syndrome, short QT syndrome, Brugada syndrome, or catecholamlnerglc 49. Are you on a special diet or do you avoid certain types of foods? polymorphic ventricular tachycardia? 50. Have you ever had an eating disorder'/ 15. Does anyone In your family have aheart problem, pacemaker, or Implanted dafiMIIator? 51. Do you have any concerns that you would like to discuss wHh adoctor? 16. Has anyone in your family had unexplained fainting, unexplained FEIIALEI ONLY seizures, or near drowning? 52. Have you ever had amenstrual period? BONE AND JOINT QUEITIOfiS Ylll No 53. How old were you when you had your first menstrual period? 17. Have you ever had an Injury to abone, muscle, ligament, or tendon 54. How many periods have you had In the last 12 months? that caused you to miss apractice or a game? Explain "yes" answers here 18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an Injury that required x-rays. MRI, CT scan, Injections, therapy, a brace, acast, or crutches? 20. Have you ever had astress fracture? 21. Have you aver been tOld that you have or have you had an x-ray for neck Instability or atlantoaxial Instability? (Down syndrome or dwarfism) 22. Do you regularly use abrace, oohotlcs, or oilier asslsHve device? 23. Do you have abone, muscle, or Joint InJury that bothers you? 24. Do any or your jOints become painful, swollen, feel warm, or look red? 25. Do you have any history or juvenile or connective tissue disease? I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete Signature of parent/guardian Dol• - ------ ©20 to 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 lo reprint for noncommercial, educational purposss with acknowledgment. HE0503 9-2681/0410 Page 1 01/12 3EBCO 3943
Transcript of Pre-Participation Physical Evaluation · BONE AND JOINT QUEITIOfiS Ylll No 53. How old were you...
• PREPARTICIPATION PHYSICAL EVALUATION
HISTORY FORM (Note: This form Is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form In the chart.)
Date of Exam ---------------------- - - ------------------
Name Date of birth _______ _ _
Sex Age Grade _____ Sport(s)School ----------
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies? DYes D No If yes, please identify specific allergy below. D Medicines D Pollens D Food D Stinging Insects
Explain "Yes" answers below. Cln:le questions you don't know the answers to.
GENERAL ClUESTIONI Ylll No MEDICAL QUESTIONS Yll No
1. Has adoctor ever denied or restr1cted your participation In sports for 26. Do you cough, wheeze, or have difficulty breathing du~ng or any reason? alter exercise?
2 Do you have any ongoing medical condiUons? nso. please Identity 27. Have you ever used an Inhaler or taken asthma medicine? below: D Asthma D Anemia D Diabetes D Infections 28. Is there anyone In your family who has asthma? Other: 29. Were you born without or are you missing aKidney, an eye, atesHcle
3. Have you ever span! the night in the hospital? (males), your spleen, or any other organ? 4. Have you ever had surgery? 30. Do you have groin pain or apalnlul bulge or hernia In the groin area?
HEART HEAUif CiUEmOii$ UOIIf YOU Y• No 31. Have you had Infectious mononucleosis (mono) within lhelast month? 5. Have you ever passed out or nea~y passed out DURING or 32. Do you have. any rashes, pressure sores, or other skin problems?
AFTER exercise? 33. Have you had aherpes or MRSA skin lnfectlon? 6. Have you ever had discomloo, pain, tightness, or pressure In your 34. Have you ever had ahead Injury or concussion?
chest during exercise? 35. Have you ever had ahit or blow to the head that caused confusion,
7. Does your heart ever mea or skip beats (Irregular beats) du~ng exercise? prolonged headache, or memory problems? 8. Has adoctor ever told you that you have any heart problems? Hso, 36. Do you have ahistory of seizure disorder?
check aY that apply: 37. Do you have headaches with exercise?D High blood pressure D Aheart murmur
D High chOlesterol D Aheart Infection 38. Have you ever had numbness, tingling, or weakness In your arms or D Kawasaki disease other: legs after being hit or falling?
9. Has adoctor ever ordered atest lor your heart? (For example, ECGIEKG, 39. Have you ever been unable to move your arms or lags after being hit echocardlogram) or falling?
10. Do you get llghtheaded or feel more short or breath than expected 40. Have you ever become ill while exercising In the heat? during exercise? 41. Do you get frequent muscle cramps when exercising?
11. Have you ever had an unexplained seizure? 42. Do you or someone In your family have sickle cell trait or disease? 12. Do you get more Urad or short ol breath more quicKly than your friends 43. Have you had any problems with your ayes or vision?
during exercise? 44. Have you had any eye lnju~as?
HEART HEAUH QtiEI110NI ABOUT YOUR FAIIILY Ylll No 45. Co )IIl ii wear gi1!8£8S nr conlacr lerl!llls? 13. Has any family member or relative died of heart problems or had an
46. Do you wear protective eyewear, such as goggles or aface shield?unexpected or unexplained sudden death before age 50 (Including drowning, unexplained car accident, or sudden infant death syndrome)? 47 Do you worry about your weight?
14. Does anyone In your family have hypertrophic cardiomyopathy, Marian 48. Are you trying to or has anyone recommended that you gain or syndrome, arrhythmogenlc rlgtrt vent~cular cardiomyopathy, long QT lose weight? syndrome, short QT syndrome, Brugada syndrome, or catecholamlnerglc 49. Are you on aspecial diet or do you avoid certain types of foods?polymorphic ventricular tachycardia?
50. Have you ever had an eating disorder'/15. Does anyone In your family have aheart problem, pacemaker, or
Implanted dafiMIIator? 51. Do you have any concerns that you would like to discuss wHh adoctor?
16. Has anyone in your family had unexplained fainting, unexplained FEIIALEI ONLY seizures, or near drowning? 52. Have you ever had amenstrual period?
BONE AND JOINT QUEITIOfiS Ylll No 53. How old were you when you had your first menstrual period? 17. Have you ever had an Injury to abone, muscle, ligament, or tendon 54. How many periods have you had In the last 12 months?
that caused you to miss apractice or agame? Explain "yes" answers here
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an Injury that required x-rays. MRI, CT scan, Injections, therapy, abrace, acast, or crutches?
20. Have you ever had astress fracture?
21. Have you aver been tOld that you have or have you had an x-ray for neck Instability or atlantoaxial Instability? (Down syndrome or dwarfism)
22. Do you regularly use abrace, oohotlcs, or oilier asslsHve device?
23. Do you have abone, muscle, or Joint InJury that bothers you?
24. Do any or your jOints become painful, swollen, feel warm, or look red?
25. Do you have any history or juvenile arth~ or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete Signature of parent/guardian Dol• - -----
©20 to 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 lo reprint for noncommercial, educational purposss with acknowledgment. HE0503 9-2681/0410
Page 1 01/123EBCO 3943
• 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 alot of pressure? • Do you ever feel sad, hopeless, depressed, or anxious? • Do you feel sate at your home or residence? • Have you ever tried cigarettes, chewing tobacco, snuH, or dip? • During the past 30 days, did you use chewing tobacco, snuH, or dip? • Do you drink alcohol or use any other drugs? • Have you ever taken anabolic sterOids or used any other pertonnance supplement? • Have you ever taken any supplements to help you gain or lose weight or Improve your performance? • Do you wear aseat bell, use ahelmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).
EliAMifUifiOfll Height Weight D Male D Female
BP I ( I ) Pulse VIsion R20/
MEDICAL Appearance • Marian stigmata (kyphOSCOliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, nyperlextty. myopia, MVP, aortic Insufficiency) Eyes/ears/nose/throat • Pupils equal • Hearing Lymph nodes Heart• • Murmurs (auscultation standing, supine, +/- Valsalva) • Location of point of maximal Impulse (PM I)
Pulses • Slmullanoous lemoral andmdlel ptjlliils Lungs Abdomen Genllourlnary (males only)' Skin • HSV. lesions suggestive ot MRSA, tinea corporis Neurologic • JIUSQIJ.IJSUIEW. Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hlp/thigh Knee Leg/ankle FooVtoes Functional • Duck-walk, single leg hop
"Consider ECG, echocardiogram, and referral to cardiotogy for abnormal cardiac history or &)(lim. "Consider GU exam if in private setting. Having third party pment is r!tcommended . eeonaider cognitive evaluation or b&eline neuropsychiatric t55ting if a history of significant concLI58ion.
D Cleared !or all sports wllhout restriction
D Cleared !or all sports wtthout restriction wllh recommendations for further evalua~on or treatment lor
NORMAL L20/ Corrected DY ON
AINOIIIIAI. FIIUIINIIS
D Notclearad
D Pending further evaluation
D For any sports
D ~rca~lnspo~ -------------------------------------------------------------------------------Reason
Recommendations ---------------------------------------------------------------------
I hsva examined lila abow-n1med llvdent and COfllllll led IIIII prupartlclpaUan phpiOJII evaluation. Tilt albleiO doll net pflllllnt appamnt cllnlcll corrtralndlcatlons to pnctice and participate In tile sport(s) as outlined above. Aoopy or 1111 physical axnm le 011 rtelll'd In my olfiDe and oan bo made avaiJJ.blc to lho Bllhaal at tho requeet ot the parent~. I! conditions arise after the athlete has been clearBd !or participation, 1ha pllyaiclanmay rescind lbe clearance urttn tho prOblem II ruolved and lhe pol,nUnl consequencas are cornpletely explained to the athlelll (and parents/guardians).
Name o! physician (prinVtype) ------------------------------------------------------------------ Date ---------Address ____________________________________________ Phone ________ _
Signature of physician__________________________________________~ MD or DO
©2010 American Academy ofFamily 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. l'flrmlsslon Is granted to reprint for noncommercial, educatlone/ purposes wnh acknowledgment. HEOM3 9·2681/0410
BEBCO 3943 Page 2 01/12
