■ Preparticipation Physical Evaluation HISTORY FORM

(Note:This formis tobe ﬁlledoutby the patientand parentpriorto seeing thephysician.The physician should keep this form in thechart.)

Date ofExam 	

Name	Date ofbirth 	

Sex	Age	Grade	School	Sport(s) 	

Yes	No Ifyes,pleaseidentifyspecificallergybelow.

Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS
	Yes
	No
	
1. Has a doctor ever denied or restricted your participation in sports for any reason?
			
2. Do you have any ongoing medical conditions? If so, please identify below:…Asthma …Anemia …Diabetes …Infections Other:
			
3.
	Have you ever spent the night in the hospital?
				
4. Have you ever had surgery?
			
HEART HEALTH QUESTIONS ABOUT YOU
	Yes
	No
	
5.HaveyoueverpassedoutornearlypassedoutDURINGor AFTER exercise?
			
6. Haveyoueverhaddiscomfort,pain,tightness,orpressureinyour chest duringexercise?
			
7. Doesyourhearteverraceorskipbeats(irregularbeats)duringexercise?
			
8. Hasadoctorevertoldyouthatyouhaveanyheartproblems?Ifso, check all thatapply:
□ Highbloodpressure          …A heart murmur □ Highcholesterol               …A heart infection
□ Kawasakidisease	Other: 	
			
9.Hasadoctoreverorderedatestforyourheart?(Forexample,ECG/EKG, echocardiogram)
			
10. Doyougetlightheadedorfeelmoreshortofbreaththanexpected during exercise?
			
11. Have you ever had an unexplained seizure?
			
12.Doyougetmoretiredorshortofbreathmorequicklythanyourfriends during exercise?
			
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
	Yes
	No
	
13.Hasanyfamilymemberorrelativediedofheartproblemsorhadan unexpectedorunexplainedsuddendeathbeforeage50(including drowning,unexplainedcaraccident,orsuddeninfantdeathsyndrome)?
			
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
			
15. Doesanyoneinyourfamilyhaveaheartproblem,pacemaker,or implanted defibrillator?
			
16.Hasanyoneinyourfamilyhadunexplainedfainting,unexplained seizures, or neardrowning?
			
BONE AND JOINT QUESTIONS
	Yes
	No
	
17. Haveyoueverhadaninjurytoabone,muscle,ligament,ortendon thatcaused youtomissapracticeor agame?
			
18.Haveyoueverhadanybrokenorfracturedbonesordislocatedjoints?
			
19. Haveyoueverhadaninjurythatrequiredx-rays,MRI,CTscan, injections,therapy,abrace,acast,orcrutches?
			
20. Have you ever had a stress fracture?
			
21.Haveyoueverbeentoldthatyouhaveorhaveyouhadanx-rayforneck instabilityoratlantoaxialinstability?(Downsyndromeordwarfism)
			
22. Do you regularly use a brace, orthotics, or other assistive device?
			
23. Do you have a bone, muscle, or joint injury that bothers you?
			
24.Doanyofyourjointsbecomepainful,swollen,feelwarm,orlookred?
			
25. Doyouhaveanyhistoryofjuvenilearthritisorconnectivetissuedisease?

MEDICAL QUESTIONS	Yes	No

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

27. Have you ever used an inhaler or taken asthma medicine? 28. Is there anyone in your family who has asthma?
29.Wereyoubornwithoutorareyoumissingakidney,aneye,atesticle (males),your spleen,or anyother organ?

30. Doyouhavegroinpainorapainfulbulgeorherniainthegroinarea? 31.Haveyouhadinfectiousmononucleosis(mono)withinthelastmonth? 32. Do you have any rashes, pressure sores, or other skin problems? 33. Have you had a herpes or MRSA skin infection?
34. Have you ever had a head injury or concussion?

35.Haveyoueverhadahitorblowtotheheadthatcausedconfusion, prolongedheadache,or memoryproblems?

36. Do you have a history of seizure disorder? 37. Do you have headaches with exercise?
38. Haveyoueverhadnumbness,tingling,orweaknessinyourarmsor legs after being hit orfalling?

39.Haveyoueverbeenunabletomoveyourarmsorlegsafterbeinghit or falling?

40. Have you ever become ill while exercising in the heat? 41. Do you get frequent muscle cramps when exercising?
42. Do you or someone in your family have sickle cell trait or disease? 43. Have you had any problems with your eyes or vision?
44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight?
48. Areyoutryingtoorhasanyonerecommendedthatyougainor lose weight?

49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder? 51.Doyouhaveanyconcernsthatyouwouldliketodiscusswithadoctor? FEMALES ONLY
52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months?

Explain “yes” answers here

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signatureofathlete	Signatureofparent/guardian	Date	

©2010AmericanAcademyofFamilyPhysicians,AmericanAcademyofPediatrics,AmericanCollegeofSportsMedicine,AmericanMedicalSocietyforSportsMedicine,AmericanOrthopaedic Societyfor SportsMedicine,andAmericanOsteopathicAcademyofSportsMedicine.Permissionisgrantedtoreprintfornoncommercial,educationalpurposeswithacknowledgment. HE0503 9-2681/0410