"Pre-participation Physical Evaluation Form - Maryland Public Secondary Schools Athletic Association"

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Pre-Participation Physical Evaluation
(This page to be completed by physician/nurse practitioner/physician assistant)
PHYSICAL EXAMINATION
DATE OF EXAM ____________________________
NAME ________________________________________________________
DATE OF BIRTH ____________________________
HEIGHT ________ WEIGHT _________ % BODY FAT (optional) _________________ PULSE __________ BP ______________
VISION R 20/ ________ L 20/ _______ CORRECTED? Y _____ N _____
PUPILS: EQUAL __________ UNEQUAL __________
NORMAL
ABNORMAL FINDING
INITIALS *
MEDICAL
Appearance __________________________________________________________________________________________________________
Eyes/Ears/Nose/Throat _________________________________________________________________________________________________
Lymph nodes ________________________________________________________________________________________________________
Heart _______________________________________________________________________________________________________________
Pulses ______________________________________________________________________________________________________________
Lungs ______________________________________________________________________________________________________________
Abdomen ____________________________________________________________________________________________________________
Genitalia (males only) __________________________________________________________________________________________________
Skin ________________________________________________________________________________________________________________
MUSCULOSKELETAL
Neck _______________________________________________________________________________________________________________
Back _______________________________________________________________________________________________________________
Shoulder/Arm ________________________________________________________________________________________________________
Elbow/Forearm _______________________________________________________________________________________________________
Wrist/Hand __________________________________________________________________________________________________________
Hip/Thigh ____________________________________________________________________________________________________________
Knee _______________________________________________________________________________________________________________
Leg/Ankle ___________________________________________________________________________________________________________
Foot ________________________________________________________________________________________________________________
*Station-based examination only
CLEARANCE
q
Cleared
q
Cleared after completing evaluation/rehabilitation for: _____________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
q
Not cleared for [Sport(s)]: __________________________ Reason: _________________________________________________
Recommendation: ____________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of physician/nurse practitioner/physician assistant _____________________________________ Date: ___________________
(
)
PRINT OR TYPE
Address: __________________________________________________________________________ Phone: __________________
Signature of physician/nurse practitioner/physician assistant ___________________________________________________________
PHYSICIANS STAMP:
Endorsed by the MPSSAA
© 1997
American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,
American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine
Pre-Participation Physical Evaluation
(This page to be completed by physician/nurse practitioner/physician assistant)
PHYSICAL EXAMINATION
DATE OF EXAM ____________________________
NAME ________________________________________________________
DATE OF BIRTH ____________________________
HEIGHT ________ WEIGHT _________ % BODY FAT (optional) _________________ PULSE __________ BP ______________
VISION R 20/ ________ L 20/ _______ CORRECTED? Y _____ N _____
PUPILS: EQUAL __________ UNEQUAL __________
NORMAL
ABNORMAL FINDING
INITIALS *
MEDICAL
Appearance __________________________________________________________________________________________________________
Eyes/Ears/Nose/Throat _________________________________________________________________________________________________
Lymph nodes ________________________________________________________________________________________________________
Heart _______________________________________________________________________________________________________________
Pulses ______________________________________________________________________________________________________________
Lungs ______________________________________________________________________________________________________________
Abdomen ____________________________________________________________________________________________________________
Genitalia (males only) __________________________________________________________________________________________________
Skin ________________________________________________________________________________________________________________
MUSCULOSKELETAL
Neck _______________________________________________________________________________________________________________
Back _______________________________________________________________________________________________________________
Shoulder/Arm ________________________________________________________________________________________________________
Elbow/Forearm _______________________________________________________________________________________________________
Wrist/Hand __________________________________________________________________________________________________________
Hip/Thigh ____________________________________________________________________________________________________________
Knee _______________________________________________________________________________________________________________
Leg/Ankle ___________________________________________________________________________________________________________
Foot ________________________________________________________________________________________________________________
*Station-based examination only
CLEARANCE
q
Cleared
q
Cleared after completing evaluation/rehabilitation for: _____________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
q
Not cleared for [Sport(s)]: __________________________ Reason: _________________________________________________
Recommendation: ____________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of physician/nurse practitioner/physician assistant _____________________________________ Date: ___________________
(
)
PRINT OR TYPE
Address: __________________________________________________________________________ Phone: __________________
Signature of physician/nurse practitioner/physician assistant ___________________________________________________________
PHYSICIANS STAMP:
Endorsed by the MPSSAA
© 1997
American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,
American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine
Pre-Participation Physical Evaluation
HISTORY
This page to be completed by student and parent/guardian
Name ______________________________________________________ Sex _______ Age _______ Date of Birth _____________________
Grade _____ School __________________________________ Sport(s) _________________________________________________________
Address ______________________________________________________________________________________________________________
Personal physician _____________________________________________________________________________________________________
In case of emergency, contact
Name ______________________________ Relationship _____________________ Phone (H) __________________ (W) ________________
Explain “Yes” answers below. Circle questions if you don’t know the answers.
YES
NO
YES
NO
q
q
q
q
1. Have you had a medical illness or injury since
10. Do you use any special protective or corrective
your last check up or sports physical?
equipment or devices that aren’t usually used for your sport
or position (for example, knee brace, special neck roll,
q
q
Do you have an ongoing or chronic illness?
foot orthotics, retainer on your teeth, hearing aid)?
q
q
2. Have you ever been hospitalized overnight?
q
q
11. Have you had any problems with your eyes or vision?
q
q
Have you ever had surgery?
q
q
Do you wear glasses, contacts, or protective eyewear?
q
q
3. Are you currently taking any prescription or
12. Have you ever had a sprain, strain, or swelling after injury? q
q
nonprescription (over-the-counter) medications or
q
q
pills or using an inhaler?
Have you broken or fractured any bone, or dislocated
q
q
Have you ever taken any supplements or vitamins
any joints?
to help you gain or lose weight or improve your
q
q
Have you had any other problems with pain or swelling
performance?
in muscles, tendons, bones, or joints?
q
q
4. Do you have any allergies (for example, to pollen,
If yes, check appropriate box and explain below.
medicine, food, or stinging insects)?
q Head
q Upper arm
q Hand
q Knee
q
q
q Back
q Elbow
q Finger
q Shin/calf
Have you ever had a rash or hives develop during
q Chest
q Forearm
q Hip
q Ankle
or after exercise?
q Shoulder
q Wrist
q Thigh
q Foot
q
q
5. Have you ever passed out during or after exercise?
q
q
13. Do you want to weigh more or less than you do now?
q
q
Have you ever been dizzy during or after exercise?
q
q
Do you lose weight regularly to meet weight requirements
q
q
Have you ever had chest pain during or after exercise?
for your sport?
q
q
Do you get tired more quickly than your friends do
q
q
14. Do you feel stressed out?
during exercise?
15. Record the dates of your most recent immunizations (shots) for:
q
q
Have you ever had racing of your heart or skipped
heartbeats?
Tetanus _____________________ Measles __________________
Hepatitis B ___________________ Chickenpox ________________
q
q
Have you had high blood pressure or high cholesterol?
q
q
Have you ever been told you have a heart murmur?
FEMALES ONLY
q
q
Has any family member or relative died of heart
problems or of sudden death before age 50?
16. When was your first menstrual period? __________________________
q
q
Have you had a severe viral infection (for example,
When was your most recent menstrual period? ___________________
myocarditis or mononucleosis) within the last month?
How much time do you usually have from the start of one period to the
q
q
Has a physician ever denied or restricted your
start of another? ___________________________________________
participation in sports for any heart problems?
How many periods have you had in the last year? _________________
q
q
6. Do you have any current skin problems (for example,
What was the longest time between periods in
itching, rashes, acne, warts, fungus, or blisters)?
the last year? _____________________________________________
q
q
7. Have you ever had a head injury or concussion?
q
q
Have you ever been knocked out, become unconscious,
Explain “Yes” answers here: ____________________________________
or lost your memory?
____________________________________________________________
q
q
Have you ever had a seizure?
____________________________________________________________
q
q
Do you have frequent or severe headaches?
____________________________________________________________
q
q
Have you ever had numbness or tingling in your arms,
____________________________________________________________
hands, legs, or feet?
____________________________________________________________
q
q
Have you ever had a stinger, burner, or pinched nerve?
____________________________________________________________
q
q
8. Have you ever become ill from exercising in the heat?
____________________________________________________________
q
q
9. Do you cough, wheeze, or have trouble breathing
during or after activity?
____________________________________________________________
q
q
Do you have asthma?
____________________________________________________________
q
q
Do you have seasonal allergies that require medical
____________________________________________________________
treatment?
We hereby state that, to the best of our knowledge, our answers to the above questions are complete and correct.
Signature of athlete ______________________________ Signature of parent/guardian ______________________________ Date _______________
© 1997
American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine,
American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine
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