History Form: PREPARTICIPATION PHYSICAL EVALUATION - Ohio High School Athletic Association - 2021-2022
History Form: PREPARTICIPATION PHYSICAL EVALUATION - Ohio High School Athletic Association - 2021-2022
History Form: PREPARTICIPATION PHYSICAL EVALUATION - Ohio High School Athletic Association - 2021-2022
HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name:_____________________________________________________ Date of birth: ______________ Grade in School: _______________
Date of examination: Sport(s):
Sex assigned at birth (F, M, or intersex): How do you identify your gender? (F, M, or other):
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 your allergies (i.e., medicines, pollens, food, stinging insects):
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 or guardian:
Date:
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
PREPARTICIPATION PHYSICAL EVALUATION | Ohio High School Athletic Association – 2021-2022
1. Type of disability:
2. Date of disability:
3. Classification (if available):
4. Cause of disability (birth, disease, injury, or other):
5. List the sports you are playing:
Yes No
6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “Yes” answers here:
Please indicate whether you have ever had any of the following conditions:
Yes No
Atlantoaxial instability
Radiographic (x-ray) evaluation for atlantoaxial instability
Dislocated joints (more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Difficulty controlling bowel
Difficulty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifida
Latex allergy
Explain “Yes” 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 or guardian:
Date:
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American
Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with
acknowledgment.
PREPARTICIPATION PHYSICAL EVALUATION – Ohio High School Athletic Association – 2021-2022
PHYSICIAN REMINDERS
1. Consider additional questions on more-sensitive issues.
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, e-cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: □Y □N
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
Hearta
• 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
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-
nation of those.
Name of health care professional (print or type): Date:
Address: Phone:
Signature of health care professional: _______________________________________________________________________, MD, DO, DC, NP, or PA
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
PREPARTICIPATION PHYSICAL EVALUATION | OHIO HIGH SCHOOL ATHLETIC ASSOCIATION – 2021-2022
□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of
Recommendations:
I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have
apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical
examination findings 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 medical eligibility until the problem is resolved
and the potential consequences are completely explained to the athlete (and parents or guardians).
Address: Phone:
Allergies:
Medications:
Other information:
Emergency contacts:
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine,
American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-
tional purposes with acknowledgment.
PREPARTICIPATION PHYSICAL EVALUATION | 2021-2022
THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS
UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE SCHOOL
This authorization will expire when the student is no longer enrolled as a student at the school.
NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID. IF THE
STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS AUTHORIZATION PERSONALLY.
________________________________________________________________________________________________________________________________
Student’s Signature Birth date of Student, including year
_______________________________________________________________________________________________________________________________
Name of Student's personal representative, if applicable
I am the Student's (check one): _______ Parent _______ Legal Guardian (documentation must be provided)
_______________________________________________________________________________________________________________________________
Signature of Student's personal representative, if applicable Date
A copy of this signed form has been provided to the student or his/her personal representative
PREPARTICIPATION PHYSICAL EVALUATION | 2021-2022
2021-2022 Ohio High School Athletic Association Eligibility and Authorization Statement
This document is to be signed by the participant from an OHSAA member school and by the participant’s guardian
I have read, understand and acknowledge receipt of the OHSAA Student Eligibility Guide and Checklist
https://www.ohsaa.org/Portals/0/Eligibility/OtherEligibiltyDocs/EligibilityGuideHS.pdf which contains a summary of the eligibility rules of the Ohio High
School Athletic Association. I understand that a copy of the OHSAA Handbook is on file with the principal and athletic administrator and that I may review it,
in its entirety, if I so choose. All OHSAA bylaws and regulations from the Handbook are also posted on the OHSAA website at ohsaa.org.
I understand that an OHSAA member school must adhere to all rules and regulations that pertain to the interscholastic athletics programs that the
school sponsors, but that local rules may be more stringent than OHSAA rules.
I understand that participation in interscholastic athletics is a privilege not a right.
Student Code of Responsibility
As a student athlete, I understand and accept the following responsibilities:
I will respect the rights and beliefs of others and will treat others with courtesy and consideration.
I will be fully responsible for my own actions and the consequences of my actions.
I will respect the property of others.
I will respect and obey the rules of my school and laws of my community, state and country.
I will show respect to those who are responsible for enforcing the rules of my school and the laws of
my community, state and country.
I understand that a student whose character or conduct violates the school’s Athletic Code or School
Code of Responsibility is not in good standing and is ineligible for a period as determined by the principal.
Informed Consent – By its nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and
Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is
impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and
hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, GUARDIANS OR STUDENTS
WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN OHSAA-
SPONSORED SPORT WITHOUT THE STUDENT’S AND PARENT’S/GUARDIAN’S SIGNATURE.
I understand that in the case of injury or illness requiring treatment by medical personnel and transportation to a health care facility, that a
reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-
athlete will be treated and transported via ambulance to the nearest hospital.
I consent to medical treatment for the student following an injury or illness suffered during practice and/or a contest.
To enable the OHSAA to determine whether the herein named student is eligible to participate in interscholastic athletics in an OHSAA member school, I
consent to the release to the OHSAA any and all portions of school record files, beginning with seventh grade, of the herein named student, specifically
including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s)or guardian(s), enrollment
documents, financial and scholarship records, residence address of the student, academic work completed, grades received and attendance data.
I consent to the OHSAA’s use of the herein named student’s name, likeness, and athletic-related information in reports of contests, promotional
literature of the Association and other materials and releases related to interscholastic athletics.
I understand that if I drop a class, take course work through College Credit Plus, Credit Flexibility or other educational options, this action could affect
compliance with OHSAA academic standards and my eligibility. I accept full responsibility for compliance with Bylaw 4-4, Scholarship, and the passing five
credit standard expressed therein.
I understand all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and
managed properly. Further I understand that if my student is removed from a practice or competition due to a suspected concussion, he or she will be
unable to return to participation that day. After that day written authorization from a physician (M.D. or D.O.) or another health care provider working
under the supervision of a physician will be required in order for the student to return to participation.
I have read and signed the Ohio Department of Health’s Concussion Information Sheet and have retained a copy for myself.
I have read and signed the Ohio Department of Health’s Sudden Cardiac Arrest Information Sheet and have retained a copy for myself.
By signing this we acknowledge that we have read the above information and that we consent to the herein named student’s participation.
*Must Be Signed Before Physical Examination
_____________________________________________________________________________________________________________________________________________
Student’s Signature Birth Date Grade in School Date
_____________________________________________________________________________________________________________________________________________
Parent’s or Guardian’s Signature Date
Ohio Department of Health Concussion Information Sheet
For Interscholastic Athletics
Dear Parent/Guardian and Athletes,
This information sheet is provided to assist you and your child in recognizing the signs and symptoms of a concussion. Every
athlete is different and responds to a brain injury differently, so seek medical attention if you suspect your child has a concus-
sion. Once a concussion occurs, it is very important your athlete return to normal activities slowly, so he/she does not do more
damage to his/her brain.
What is a Concussion? Seek Medical Attention Right Away
A concussion is an injury to the brain that may be caused by a Seeking medical attention is an important first step if you
blow, bump, or jolt to the head. Concussions may also happen suspect or are told your child has a concussion. A
after a fall or hit that jars the brain. A blow elsewhere on the qualified health care professional will be able to
body can cause a concussion even if an athlete does not hit determine how serious the concussion is and when it is
his/her head directly. Concussions can range from mild to safe for your child to return to sports and other daily
severe, and athletes can get a concussion even if they are activities.
wearing a helmet. i No athlete should return to activity on the same day
he/she gets a concussion.
Signs and Symptoms of a Concussion
i Athletes should NEVER return to practices/games if
Athletes do not have to be “knocked out” to have a concussion. they still have ANY symptoms.
In fact, less than 1 out of 10 concussions result in loss of
consciousness. Concussion symptoms can develop right away i Parents and coaches should never pressure any
or up to 48 hours after the injury. Ignoring any signs or athlete to return to play.
symptoms of a concussion puts your child’s health at risk! The Dangers of Returning Too Soon
Signs Observed by Parents of Guardians Returning to play too early may cause Second Impact
i Appears dazed or stunned. Syndrome (SIS) or Post-Concussion Syndrome (PCS).
i Is confused about assignment or position. SIS occurs when a second blow to the head happens
i Forgets plays. before an athlete has completely recovered from a
i Is unsure of game, score or opponent. concussion. This second impact causes the brain to
swell, possibly resulting in brain damage, paralysis, and
i Moves clumsily. even death. PCS can occur after a second impact. PCS
i Answers questions slowly. can result in permanent, long-term concussion
i Loses consciousness (even briefly). symptoms. The risk of SIS and PCS is the reason why
i Shows behavior or personality changes (irritability, no athlete should be allowed to participate in any
sadness, nervousness, feeling more emotional). physical activity before they are cleared by a qualified
i Can’t recall events before or after hit or fall. healthcare professional.
hƩp://www.healthy.ohio.gov/vipp/child/returntoplay/concussion
Rev. 09.16
Ohio Department of Health Concussion Information Sheet
For Interscholastic Athletics
I have read the Ohio Department of Health’s Concussion Information Sheet and
understand that I have a responsibility to report my/my child’s symptoms to coaches,
administrators and healthcare provider.
I also understand that I/my child must have no symptoms before return to play can
occur.
Athlete Date
Parent/Guardian Date
Rev. 9.16
Sudden Cardiac Arrest and Lindsay’s Law
Parent/Athlete Signature Form
What is Lindsay’s Law? Lindsay’s Law is about Sudden Cardiac Arrest (SCA) in youth athletes. It covers all athletes 19 years or younger
who practice for or compete in athletic activities. Activities may be organized by a school or youth sports organization.
What is SCA? SCA is when the heart stops beating suddenly and unexpectedly. This cuts off blood flow to the brain and other vital
organs. People with SCA will die if not treated immediately. SCA can be caused by 1) a structural issue with the heart, OR 2) an heart
electrical problem which controls the heartbeat, OR 3) a situation such as a person who is hit in the chest or a gets a heart infection.
What is a warning sign for SCA? If a family member died suddenly before age 50, or a family member has cardiomyopathy, long QT
syndrome, Marfan syndrome or other rhythm problems of the heart.
What symptoms are a warning sign of SCA? A young athlete may have these things with exercise:
• Chest pain/discomfort
• Unexplained fainting/near fainting or dizziness
• Unexplained tiredness, shortness of breath or difficulty breathing
• Unusually fast or racing heart beats
What happens if an athlete experiences syncope or fainting before, during or after a practice, scrimmage, or competitive
play? The coach MUST remove the youth athlete from activity immediately. The youth athlete MUST be seen and cleared by a health care
provider before returning to activity. This written clearance must be shared with a school or sports official.
What happens if an athlete experiences any other warning signs of SCA? The youth athlete should be seen by a health care professional.
Who can evaluate and clear youth athletes? A physician (MD or DO), a certified nurse practitioner, a clinical nurse specialist,
certified nurse midwife. For school athletes, a physician’s assistant or licensed athletic trainer may also clear a student. That person
may refer the youth to another health care provider for further evaluation.
What is needed for the youth athlete to return to the activity? There must be clearance from the health care provider in writing.
This must be given to the coach and school or sports official before return to activity.
All youth athletes and their parents/guardians must review information about Sudden Cardiac Arrest, then sign and return this form.
_____________________________________ ___________________________________
Parent/Guardian Signature Student Signature
______________________________________ ____________________________________
Parent/Guardian Name (Print) Student Name (Print)
______________________________________ _______________________________________
Date Date
Department Department
of Health of Education