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

1. Have you had a medical illness or injury since q q 10. Do you use any special protective or corrective q q
your last check up or sports physical? equipment or devices that aren’t usually used for your sport
Do you have an ongoing or chronic illness? q q or position (for example, knee brace, special neck roll,
foot orthotics, retainer on your teeth, hearing aid)?
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 q q
nonprescription (over-the-counter) medications or 12. Have you ever had a sprain, strain, or swelling after injury? 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 q q any joints?
to help you gain or lose weight or improve your Have you had any other problems with pain or swelling q q
performance? in muscles, tendons, bones, or joints?
4. Do you have any allergies (for example, to pollen, q q If yes, check appropriate box and explain below.
medicine, food, or stinging insects)? q Head q Upper arm q Hand q Knee
Have you ever had a rash or hives develop during q q q Back q Elbow q Finger q Shin/calf
or after exercise? q Chest q Forearm q Hip q Ankle
5. Have you ever passed out during or after exercise? q q q Shoulder q Wrist q Thigh q Foot
Have you ever been dizzy during or after exercise? q q 13. Do you want to weigh more or less than you do now? q q
Have you ever had chest pain during or after exercise? q q Do you lose weight regularly to meet weight requirements q q
for your sport?
Do you get tired more quickly than your friends do q q
during exercise? 14. Do you feel stressed out? q q
Have you ever had racing of your heart or skipped q q 15. Record the dates of your most recent immunizations (shots) for:
heartbeats? Tetanus _____________________ Measles __________________
Have you had high blood pressure or high cholesterol? q q Hepatitis B ___________________ Chickenpox ________________
Have you ever been told you have a heart murmur? q q
Has any family member or relative died of heart q q FEMALES ONLY
problems or of sudden death before age 50? 16. When was your first menstrual period? __________________________
Have you had a severe viral infection (for example, q q 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
Has a physician ever denied or restricted your q q start of another? ___________________________________________
participation in sports for any heart problems? How many periods have you had in the last year? _________________
6. Do you have any current skin problems (for example, q q What was the longest time between periods in
itching, rashes, acne, warts, fungus, or blisters)? the last year? _____________________________________________
7. Have you ever had a head injury or concussion? q q
Have you ever been knocked out, become unconscious, q q Explain “Yes” answers here: ____________________________________
or lost your memory?
____________________________________________________________
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, q q
hands, legs, or feet? ____________________________________________________________
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 q q ____________________________________________________________
during or after activity? ____________________________________________________________
Do you have asthma? q q ____________________________________________________________
Do you have seasonal allergies that require medical q q
____________________________________________________________
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