preparticipation physical evaluation i€¦ · date of exam _ history name grade __ school address...
TRANSCRIPT
DATE OF EXAM _HISTORY
Name
Grade __ School
Address
Preparticipation Physical EvaluationI
Sex Age Date of birth _
Sport(s)
phone _
Personal physician
In case of emergency, contact
Name Relationship Phone (H)
1. Have you had a medical illness or Injury since yourlast check up or sports physical?
Do you have an ongoing or chronic illness?2. Have you ever been hospitalized overnight?
Have you ever had surgery?3. Are you currently taking any prescription or
nonprescription (over-the-counter) medications or
pills or using an inhaler?Have you ever taken any supplements or vitamins tohelp you gain or lose weight or improve yourperformance?
4. Do you have any allergies (for example, to pollen,medicine, food, or stinging insects)?
Have you ever had a rash or hives develop during orafter exercise?
5. Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?Have you ever had chest pain during or after exercise?.00 you got tired more quickly than your friends doduring exercise?
Have you ever had racing of your heart or skippedheartbeats?
Have you had high blood pressure or high cholesterol?
Have you ever been told you have a heart murmur'?Has any family member or relative died of heart
problems or of sudden death before age 50?Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?Has a physician ever denied or restricted your
participation in sports for any heart problems?6. Do you have any current skin problems (for example,
itching, rashes, acne, warts, fungus, or blisters)?7. Have you ever had a head Injury or concussion?
Have you ever been knocked out, becomeunconscious, or lost your memory?
Have you ever had a seizure?Do you have frequent or severe headaches?Have you ever had numbness or tingling in your arms,hands, legs, or feet?
Have you ever had a stinger, burner, or pinched nerve?S. Have you ever become ill from exercising In the heat?
9. Do you cough, wheeze, or have trouble breathingduring or after activity?
Do you have asthma?
Do you have seasonal allergies that require medicaltreatment?
13. Do you want to weigh more or less than you do now? 0Do you lose weight regularly to meet weight 0requirements for your sport?
14. Do you feel stressed out? 015. Record the dates of your most recent immunizations /
(shots) for:Tetanus Measles
Hepatitis B Chickenpox _FEMALES ONLY
16. When was your first menstrual period? _
When was your most recent menstrual period? _How much time do you usually have from the start of one
period to the start of another? _
How many periods have you had in the last year'?What was the longest time between periods in the last year? _Explain "Yes" answers here:
o Hip
o Thigho Kneeo Shin/calf
o Ankleo Foot
Explain 'Yes" answers below.Circle questions you don't know the answers to.
Yes No0
00
00
00
00
0
0
0
0
0
0
0
0
00
00
00
0
0
00
00
00
00
00
0
0
0
0
00
00
00
00
0
0
00
00
00
00
010. Do you use any special protective or corrective
equipment or devices that aren't usually used for
your sport or position (for example, knee brace,
special neck roll, foot orthotics, retainer on yourteeth, hearing aid)?
11. Have you had any problems with your eyes or vision?Do you wear glasses, contacts, or protective eyewear?
12. Have you ever had a sprain, strain, or swelling after
injury?Have you broken or fractured any bones or dislocated
any joints?Have you had any other problems with pain orswelling In muscles, tendons, bones, or joints?
If yes, check appropriate box and explain below
o Head 0 Elbowo Neck 0 Forearm
o Back 0 Wrist
o Chest 0 Hando Shoulder 0 Finger
o Upper arm
Yes
o
oooo
o
Noo
ooooo
oo
o
I hereby state that, to the beat of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete Signature of parent/guardian Date
a 1997 American Academy of Family Physidans, American Academy of Pediatrics, American Medical Society for Sports Medidne, American Orthopaedic Society for Sports Medicine, andAmerican Osteopathic Academy of Sports Medicine.
Page 1
NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits andtriennially for the Committee on Special Education (CSE).
HEALTH APPRAISAL FORM
Name: _ Date of Birth: _
,··3~;i. ··..c· '. '", . : ..... < "<',' . ','
Date:
Date: _Date: _Date: _
ONegativeO Not doneONegative 0 Not doneo No 0 Not doneo No 0 Not done
~r;:;\P(it.4··9t?7'IMMUN'2!ATIOijs:TfiEAL'rHIHi$T(iRYP
. Sickle Cell Screen: 0 PositivePPD: 0 PositiveElevated Lead: 0 YesDental Referral 0 Yes
School: _~ .,.---
o Immunization record attached
o No immunizations given todayo Immunizations given since last Health Appraisal:
Significant MedlcaUSurgical History: 0 See attached _
o Asttima-": --:·~1oDiat>etes:·J:'J~T~ i', 0 T~ 2<,,00tt\er.", ,', .?~.':.,',',.;." .': ':--~:.: ....H~;:;:·'··c·,····O'I~: OOther. ' _Allergies: 0 UFE THREATENING
o Seasonal o Medication: _
Date of Exam: _Height: _ Weight: _ Btood Pressure: _
VISion - without glasses/contact lenses
Vision - with glasses/contact lenses
Vision - Near Point
Hearing (J Pass 20 db sc both ears or.
R
R
R
R
L
L
L
L
Referral
o EXAM ENTIRELY NORMAL Tanner. I. II. If I. IV, V, Scoliosis: 0 Negative 0 Positive: _
Specify any abnormality (use reverse of form if needed): _
Medications (list all):
.. !'; . F,,,.·::lt;;;.~";g•• I;Dj(:41iC)N$kr)~;;;:o None 0 Additional medications listed on reverse of form
Name: _Name: _
Dosageffime: _
Dosageffime: _
If AM dose is missed at home: _
I assess this student to be self-directed 0 Yes 0 No Student may self carry and self administer medication 0 Yes 0 NoNote: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency
sheltering is necessary at school or if the morning medication has not been given.·,.,*;O:/\ff· ~iW::S;~~~~~.ijc~ATt~f'"'••eo:~1fm1l~tQ08O;ViWQW81t§ij~'"'~fj~I~~t~~~nQ.iI~~j1i;i)~tr$'~f'£1;,1o Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked:
_ Umited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball._ Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, riflery, weight train, crew, dance, track. run, walk, rope jump.
o Specify medical accommodations needed for school: 0 None
o Known or suspected disability: _
o Restrictions: _
o Please monitor
o Please monitor
o Protective equipment required: 0 Athletic Cup 0 Sport goggleslimpact resistant eyewear 0 Other: _(Stamp below)
Provider's Signature: _
Provider's Name/Address: _
Phone: _
Fax: _
Parent Signature: Date: _This exam complies witt! NYSED requiraments above and is valid for twelve months, witt! the exception of any iHness or injury lasting more than five
days that will require review by private heaJthcare provk:Jer and the school medical diredor. Rev. 1013107