"Mshsaa Pre-participation Physical Evaluation"

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Revised 6/2019
PRE-PARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM – VALID FOR 2 YEARS
Name:
Date of Birth:
Physician Reminders:
1.
Consider additional questions on more-sensitive issues.
 Do you drink alcohol or use any other drugs?
 Do you feel stressed out or under a lot of pressure?
 Have you ever taken anabolic steroids or used any other performance-enhancing
 Do you ever feel sad, hopeless, depressed or anxious?
supplement?
 Do you feel safe at your home or residence?
 Have you ever taken any supplements to help you gain or lose weight or improve
 Have you ever tried cigarettes, chewing tobacco, snuff or dip?
your performance?
 During the past 30 days, did you use chewing tobacco, snuff or dip?
 Do you wear a seat belt, use a helmet and use condoms?
2.
Consider reviewing questions on cardiovascular symptoms (Questions 4-13 of History Form).
EXAMINATION
Height:
Weight:
BP:
/
(
/
)
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 insufficiency)
Eyes, ears, nose and throat
 Pupils equal
 Hearing
Lymph Nodes
Heart*
 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 fingers
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
* Consider electrocardiography (ECG), echocardiogram, referral to cardiology for abnormal cardiac history or examination findings, or a combination of those.
Cleared for all sports without restriction for two (2) years.
☐ Cleared for all sports without restriction for two (2) years with recommendation for further evaluation or treatment for:
☐ Cleared for all sports without restriction for less than two (2) years. Specify reasons and duration of approval below:
☐ Not Cleared
☐ Pending further evaluation
☐ For any sports
☐ For certain sports (please list):
Reason:
Recommendations/Comments:
I have examined the above-named student and completed the pre-participation physical evaluation. The athlete does not present apparent clinical contraindications to practice
and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office 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 clearance until the problem is resolved and the potential consequences are
completely explained to the athlete (and parents/guardians).
Name of healthcare professional (type/print):
Date of Issue:
Address:
Phone:
Signature of healthcare professional (MD/DO/ARNP/PA/Chiropractor):
This physical is valid for a 2-year period unless otherwise noted by the physician in the “Recommendations” field listed above.
Revised 6/2019
PRE-PARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM – VALID FOR 2 YEARS
Name:
Date of Birth:
Physician Reminders:
1.
Consider additional questions on more-sensitive issues.
 Do you drink alcohol or use any other drugs?
 Do you feel stressed out or under a lot of pressure?
 Have you ever taken anabolic steroids or used any other performance-enhancing
 Do you ever feel sad, hopeless, depressed or anxious?
supplement?
 Do you feel safe at your home or residence?
 Have you ever taken any supplements to help you gain or lose weight or improve
 Have you ever tried cigarettes, chewing tobacco, snuff or dip?
your performance?
 During the past 30 days, did you use chewing tobacco, snuff or dip?
 Do you wear a seat belt, use a helmet and use condoms?
2.
Consider reviewing questions on cardiovascular symptoms (Questions 4-13 of History Form).
EXAMINATION
Height:
Weight:
BP:
/
(
/
)
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 insufficiency)
Eyes, ears, nose and throat
 Pupils equal
 Hearing
Lymph Nodes
Heart*
 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 fingers
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
* Consider electrocardiography (ECG), echocardiogram, referral to cardiology for abnormal cardiac history or examination findings, or a combination of those.
Cleared for all sports without restriction for two (2) years.
☐ Cleared for all sports without restriction for two (2) years with recommendation for further evaluation or treatment for:
☐ Cleared for all sports without restriction for less than two (2) years. Specify reasons and duration of approval below:
☐ Not Cleared
☐ Pending further evaluation
☐ For any sports
☐ For certain sports (please list):
Reason:
Recommendations/Comments:
I have examined the above-named student and completed the pre-participation physical evaluation. The athlete does not present apparent clinical contraindications to practice
and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office 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 clearance until the problem is resolved and the potential consequences are
completely explained to the athlete (and parents/guardians).
Name of healthcare professional (type/print):
Date of Issue:
Address:
Phone:
Signature of healthcare professional (MD/DO/ARNP/PA/Chiropractor):
This physical is valid for a 2-year period unless otherwise noted by the physician in the “Recommendations” field listed above.
Revised 6/2019
MEDICAL HISTORY
Note: Complete and sign this form (with your parents if younger than 18) before your appointment. The physician should keep a copy of this form in the chart for their records.
Note: An injury or medical condition results in a separate medical release.
Name:
Date of Birth:
Date of examination:
Sex assigned at birth (F, M or intersex):
How do you identify your gender? (F, M or other):
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 of your allergies (i.e., 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 (circle response).
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.
Revised 6/2019
Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.
GENERAL QUESTIONS
Yes
No
MEDICAL QUESTIONS
Yes
No
1. Do you have any concerns that you would like to discuss with
16. Do you cough, wheeze, or have difficulty breathing during or
your provider?
after exercise?
2. Has a provider ever denied or restricted your participation in
17. Are you missing a kidney, an eye, a testicle (males), your
sports for any reason?
spleen or any other organ?
3. Do you have any ongoing medical issues or recent illness?
18. Do you have groin or testicle pain or a painful bulge or hernia
in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
19. Do you have any recurring skin rashes or rashes that come
4. Have you ever passed out or nearly passed out during or
and go, including herpes or methicillin-resistant
after exercise?
Staphylococcus aureus (MRSA)?
5. Have you ever had discomfort, pain, tightness, or pressure in
20. Have you had a concussion or head injury that caused
your chest during exercise?
confusion, a prolonged headache or memory problems?
6. Does your heart ever race or skip beats (irregular beats)
21. Have you ever had numbness, had tingling, had weakness in
during exercise?
your arms or legs, or been unable to move your arms or legs
7. Has a doctor ever told you that you have any heart
after being hit or falling?
problems?
22. Have you ever become ill while exercising in the heat?
8. Has a doctor ever ordered a test for your heart? (For
23. Do you, or does someone in your family, have sickle cell trait
example, electrocardiography (ECG) or echocardiography?
or disease?
9. Do you get light-headed or feel shorter of breath than your
24. Have you ever had, or do you have, any problems with your
friends during exercise?
eyes or vision?
10. Have you ever had a seizure?
25. Do you worry about your weight?
26. Are you trying to, or has anyone recommended, that you gain
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes
No
or lose weight?
11. Has any family member or relative died of heart problems or
27. Are you on a special diet or do you avoid certain types of
had an unexpected or unexplained sudden death before age
foods or food groups?
35 (including drowning or unexplained car crash)?
28. Have you ever had an eating disorder?
12. Does anyone in your family have a genetic heart problem
FEMALES ONLY
Yes
No
such as hypertrophic cardiomyopathy (HCM), Marfan
syndrome, arrhythmogenic right ventricular cardiomyopathy
29. Have you ever had a menstrual period?
(ARVC), long QT syndrome (LQTS), short QT syndrome
30. How old were you when you had your first menstrual period?
(SQTS), Brugada syndrome or catecholaminergic
31. When was your most recent menstrual period?
polymorphic ventricular tachycardia (CPVT)?
32. How many periods have you had in the past 12 months?
13. Has anyone in your family had a pacemaker or an implanted
defibrillator before age 35?
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?
IF “YES,” EXPLAIN ANSWERS HERE
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(s) or Guardian:
Date:
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