"Pre-participation Examination Form - Lewis&clark Community College"

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Do you get tired more quickly than your friends do
during exercise?
_______________
Pre-participation Examination
Have you ever had racing of your heart or skipped
heartbeats?
_______________
To be completed by athlete or parent
Have you had high blood pressure or high
cholesterol?
_______________
Name_______________________________________________ Sport/Position________________
Have you ever been told you have a heart murmur?
_______________
Last
First
Middle
Has any family member or relative died or heart
problems or of sudden death before age 50?
_______________
Have you had a severe viral infection (for example
Social Security Number ________________________________ School Year ___________________
myocarditis or mononucleosis) within the past
College Address ___________________________________________________________________
month?
_______________
Has a physician ever denied or restricted your
City/State __________________________________________ Phone No. ____________________
participation in sports for any heart problems?
_______________
Date of Birth________________________ Age _______ Cell Phone No. ______________________
Has anyone in your family had a heart attack before
the age of 50?
_______________
Parent’s Name ____________________________________________________________________
15. Head and Nerve
Home Address _____________________________________________________________________
Have you ever had a head injury or concussion?
_______________
Have you ever been knocked out, become
Phone No. ___________________________________
unconscious, or lost your memory?
_______________
Person to contact in case of emergency ________________________________________________
Have you ever had a seizure?
_______________
Do you have frequent or severe headaches?
_______________
Phone No. ___________________________________
Have you ever had numbness or tingling in your
Family Doctor _______________________________ City/State ____________________________
arms, hands, legs, or feet?
_______________
Have you ever had a stinger, burner or pinched
Phone No. ___________________________________
nerve?
_______________
16. Last tetanus shot
Date ___________________
PAST MEDICAL HISTORY
Yes
No
If yes, please explain
(what, where, when)
17. Last eye exam
Date ___________________
1.
Presently taking medication (including birth control
18. Last menstrual period (If women)
Date ___________________
pills)?
_______________
2.
Have you been diagnosed with asthma?
_______________
3.
Have you been prescribed by a physician to use an
PERSONAL HABITS
Yes
No
asthma medication?
_______________
1.
Smoking/smokeless tobacco
4.
Allergic to medicine, food, bee stings?
_______________
2.
Alcohol/non-medical drugs: marijuana, cocaine, etc
5.
Wears any appliances – glasses, contact lenses?
_______________
3.
Steroids
6.
History of braces, chipped teeth, bridges?
_______________
4.
Eating Disorders – weight loss or gain?
7.
Has ongoing medical problem?
_______________
Review of systems
(Please check if you have any problems with any of the following areas of your
8.
Had serious or significant illness in past?
_______________
body)
9.
Any past surgical operations, accidents, non-sports or
Skin
Head
Shoulders, Arms
related injuries?
_______________
Fatigue
Heart
Mouth/Throat
10. Any past injuries directly related to sports?
_______________
Neck
Eyes
Hips, Legs, Feet
11. Any hospitalization not explained above?
_______________
Hands
Ears
Mental, Emotional
12. Any known deformities (such as curvature of back, heart
Back
Nose
Muscles-Strength, Feeling
problems, one kidney, blindness in one eye, one testicle,
Lungs
Abdomen
Nutrition, Weight Control
etc.)?
_______________
Genital (including menstrual for women
Other: What? ____________________
13. Any serious family illness (such as diabetes, bleeding
disorders, etc.)?
_______________
I certify that the above information is correct to the best of my knowledge.
14. Heart
Have you ever passed out during or after exercise?
_______________
Student Signature _______________________________________________________________
Have you ever been dizzy during or after exercise?
_______________
Have you ever had chest pain during or after exercise?
_______________
Do you get tired more quickly than your friends do
during exercise?
_______________
Pre-participation Examination
Have you ever had racing of your heart or skipped
heartbeats?
_______________
To be completed by athlete or parent
Have you had high blood pressure or high
cholesterol?
_______________
Name_______________________________________________ Sport/Position________________
Have you ever been told you have a heart murmur?
_______________
Last
First
Middle
Has any family member or relative died or heart
problems or of sudden death before age 50?
_______________
Have you had a severe viral infection (for example
Social Security Number ________________________________ School Year ___________________
myocarditis or mononucleosis) within the past
College Address ___________________________________________________________________
month?
_______________
Has a physician ever denied or restricted your
City/State __________________________________________ Phone No. ____________________
participation in sports for any heart problems?
_______________
Date of Birth________________________ Age _______ Cell Phone No. ______________________
Has anyone in your family had a heart attack before
the age of 50?
_______________
Parent’s Name ____________________________________________________________________
15. Head and Nerve
Home Address _____________________________________________________________________
Have you ever had a head injury or concussion?
_______________
Have you ever been knocked out, become
Phone No. ___________________________________
unconscious, or lost your memory?
_______________
Person to contact in case of emergency ________________________________________________
Have you ever had a seizure?
_______________
Do you have frequent or severe headaches?
_______________
Phone No. ___________________________________
Have you ever had numbness or tingling in your
Family Doctor _______________________________ City/State ____________________________
arms, hands, legs, or feet?
_______________
Have you ever had a stinger, burner or pinched
Phone No. ___________________________________
nerve?
_______________
16. Last tetanus shot
Date ___________________
PAST MEDICAL HISTORY
Yes
No
If yes, please explain
(what, where, when)
17. Last eye exam
Date ___________________
1.
Presently taking medication (including birth control
18. Last menstrual period (If women)
Date ___________________
pills)?
_______________
2.
Have you been diagnosed with asthma?
_______________
3.
Have you been prescribed by a physician to use an
PERSONAL HABITS
Yes
No
asthma medication?
_______________
1.
Smoking/smokeless tobacco
4.
Allergic to medicine, food, bee stings?
_______________
2.
Alcohol/non-medical drugs: marijuana, cocaine, etc
5.
Wears any appliances – glasses, contact lenses?
_______________
3.
Steroids
6.
History of braces, chipped teeth, bridges?
_______________
4.
Eating Disorders – weight loss or gain?
7.
Has ongoing medical problem?
_______________
Review of systems
(Please check if you have any problems with any of the following areas of your
8.
Had serious or significant illness in past?
_______________
body)
9.
Any past surgical operations, accidents, non-sports or
Skin
Head
Shoulders, Arms
related injuries?
_______________
Fatigue
Heart
Mouth/Throat
10. Any past injuries directly related to sports?
_______________
Neck
Eyes
Hips, Legs, Feet
11. Any hospitalization not explained above?
_______________
Hands
Ears
Mental, Emotional
12. Any known deformities (such as curvature of back, heart
Back
Nose
Muscles-Strength, Feeling
problems, one kidney, blindness in one eye, one testicle,
Lungs
Abdomen
Nutrition, Weight Control
etc.)?
_______________
Genital (including menstrual for women
Other: What? ____________________
13. Any serious family illness (such as diabetes, bleeding
disorders, etc.)?
_______________
I certify that the above information is correct to the best of my knowledge.
14. Heart
Have you ever passed out during or after exercise?
_______________
Student Signature _______________________________________________________________
Have you ever been dizzy during or after exercise?
_______________
Have you ever had chest pain during or after exercise?
_______________
PHYSCIAL EXAMINATION
Height _________________ Weight ___________________ Blood Pressure _______________
Pulse: resting _____________ 1 min. exercise_______________ after 1 min. rest___________
_______________________________________________________
Student’s Name
Pulse Ox: Resting___________ 1 min. exercise ______________ after 1 min. rest ___________
Visual Acuity: Eyes (R) 20/ ___________ (L) 20/___________ Corrected: ____Y ____N
Finger-tip span: ___________________________________ BMI:_________________________
Other Testing
Normal
Abnormal Findings
1.
General
______________________________________
2.
Skin
______________________________________
3.
HEENT
______________________________________
4.
Teeth (Dental Exam)
______________________________________
5.
Neck
______________________________________
6.
Lungs
______________________________________
7.
Heart (Sit and Stand)
______________________________________
8.
Abdomen
______________________________________
9.
Genitalia
______________________________________
10. Musculoskeletal
Neck
______________________________________
Shoulder/Arm
______________________________________
Elbow/Forearm
______________________________________
Wrist/Hand
______________________________________
Back
______________________________________
Hip/Thigh
______________________________________
Knee
______________________________________
Shin/Calf
______________________________________
Athletic Physical
Ankle/Leg
______________________________________
Foot
______________________________________
11. Peripheral Pulses
______________________________________
12. Neurologic
______________________________________
13. Mental Status
______________________________________
14. Marfan Screen
______________________________________
Other Tests (optional)
Auditory
UA
EKG
Hgb/Hct
Tanner Stage
% Body Fat
Drug Screen
Chest X-Ray
SMAC
On the basis of the examination on this day, I approve this student’s participation in
interscholastic sports for one year.
Yes
No
Limited
Additional Comments:
____________________________________________
_____________________
Physician/APN/PA Signature
Date
__________________________________________
______________________
Trainer’s Signature
Date
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