UC Irvine Club Sports

Pre-Participation Requirements
New Athlete Physical
Welcome to UC Irvine Club Sports!

This New Athlete Physical is to be complete by club sports members who…

1. Are new UCI Club Sports participants
2. DID NOT receive approval for the Comprehensive Health History or Annual Health History
requirement on Do Sports Easy for the 2023-2024 season.
OR
3. Were instructed by the athletic training/sports medicine staff of UCI Club Sports to complete a
physical for the 2024-2025 season.

INSTRUCTIONS
1. Complete the Health History Questionnaire (pages 1-4) to the best of your abilities. Provide
as much detail as possible where necessary to avoid delays. Failure to follow instructions may
result in delays.
a. For participants under 18 years of age at the time of signing this document, a
parent/guardian signature is required.
2. Make an appointment for a physical examination with a medical provider (MD, DO, NP, or PA
ONLY). Evaluations from a chiropractor are not accepted.
a. Students with UCSHIP - Please call the UCI Student Health Center at 949-824-5304 and
make an appointment with Dr. Tsai or Dr. Nghiem for a sports physical for club sports.
b. Students without UCSHIP (personal insurance) - Please make an appointment with
your primary care provider for a physical.
3. Print the Health History Questionnaire & Physical Exam (pages 1-6).
4. Take your Health History Questionnaire (completed) and Physical Exam to your scheduled
physical appointment for the medical provider (MD, DO, NP, PA) to review and complete.
a. Students with UCSHIP – Upload to your patient portal PRIOR to your appointment
5. Please upload the signed and completed Health History Questionnaire AND Physical Exam
(pages 1-6) to DocuSign for athlete training staff to review.
6. FORMS ARE ONLY ACCEPTED VIA DOCUSIGN. PLEASE DO NOT SEND RESPONSES VIA EMAIL.

NEW ATHLETE PHYSICAL DEADLINES

• Available for submission on DocuSign 9/9/24-5/16/25, HOWEVER, they will not be reviewed by
athletic training staff the last 2 weeks of each quarter.
• Allow a MINIMUM of 2 weeks for the athletic training and sports medicine staff to review the
submitted form for approval on DSE. Last minute submissions to meet travel & competition
deadlines WILL NOT be granted.
• PLEASE PLAN ACCORDINGLY TO YOUR COMPETITION SCHEDULE AND ALLOW A MINIMUM OF 2
WEEKS FOR APPROVAL AS UCI CLUB SPORTS HAS 39 CLUBS AND OVER 2400 PARTICIPANTS.
• Failure to follow instructions may result in delays.

The personal and private health information provided are only accessible by the athletic training, sports medicine,
and administrative professionals of UCI Club Sports.
Your club sports participation status is contingent on the approval of ALL requirements on Do Sports Easy.

Please email the Club Sports Athletic Trainer at [email protected] with questions or concerns.
 What is this
UC Irvine Club Sports
Health History Questionnaire
Chuyue
Name __________________________________________ Date of Birth ______________________
Jiang 02 01 2006
Year in School ________________ Sport(s) ______________________________________________________
I
female Badmintgemale.CO
Sex assigned at birth __________________ Gender identity ___________________ UCSHIP YES NO
0
949 372
Phone ___________________
0393 Email ________________________________
uci.edu
chuyuejI
Student ID __________________
39659918
Please read carefully and complete to the best of your abilities and knowledge. All answers need detailed explanation.

MEDICAL HISTORY
1. Do you have any past and current medical conditions? If yes, please list and provide details.

⽘
2. Have you ever had surgery? If yes, list all past surgical procedures.

3. Are you taking any medications and supplements? If yes, list all current prescriptions, over the counter medicines, and
supplements.

⽘
4. Do you have any allergies? If yes, please list all your allergies.

If you selected any of the answers “yes” on PAGES 1-4, please explain and provide as much detail as possible in the
space provided after each section. Include information such as past history, diagnosis, treatment, current condition,
etc. Failure to do so may result in delays.

GENERAL QUESTIONS YES NO

5. Do you have any concerns that you would like to discuss with a healthcare provider?
6. Has a healthcare provider ever denied or restricted your participation in sport for any
reason?
7. Do you have any ongoing medical issues or recent illness?

Explain “yes” answers for General Questions 5-7 here.

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 1
 PERSONAL HEART HEALTH QUESTIONS YES NO
8. Have you ever passed out or nearly passed out during exercise?
9. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
10. Does your heart ever race, flutter in your chest, or skip beats (irregular beats during
ˇ
exercise?) ˇ
11. Has a doctor ever told you that you have any heart problems?
12. Has a doctor ever requested a test for your heart? For example, electrocardiography
ˇ
(ECG) or echocardiography? v
13. Do you get light headed or feel shorter of breath than your friends during exercise?
14. Have you ever had a seizure?

Explain “yes” answers for Personal Heart Health 8-14 here.

FAMILY HEART HEALTH QUESTIONS YES NO

15. Has any family member or relative died of heart problems or had an unexpected or
unexplained sudden death before age 35 years (including drowning or unexplained car
crash)?
16. Does anyone in your family have a genetic heart problem, such as hypertrophic
cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular
cardiomyopathy (ARVC), long QT syndrome, short QT syndrome, Brugada syndrome, or ˇ
catecholaminergic poly-morphic ventricular tachycardia (CPVT)?
17. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35? ˇ
Explain “yes” answers for Family Heart Health 15-17 here.

BONE AND JOINT QUESTIONS YES NO

18. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon

ˇ
that caused you to miss a practice or game?
19. Do you have a bone, muscle, ligament, or joint injury that bothers you?

Explain “yes” answers for Bone & Joint 18-19 here.

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 2
 MEDICAL QUESTIONS YES NO
20. Do you cough, wheeze, or have difficulty breathing during or after exercise?
21. Are you missing a kidney, an eye, a testicle, spleen or any other organ?
22. Do you have groin or testicle pain or painful bulge/hernia in the groin area? 三
23. Do you have any recurring skin rashes or rashes (not including eczema) that come and go,
including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

ǔ
24. Have you had a concussion or head injury that caused confusion, a prolonged headache, or
memory problems? If yes, in the space below answer the following questions: 1. Number of
concussions you’ve had in the past year, 2. Number of concussions you’ve had total in your
lifetime, 3. Do you have any current issues/symptoms?
25. Have you ever had numbness, tingling, weakness in your arms or legs, or been unable to
move your arms or legs after being hit or falling?
26. Have you ever become ill while working or exercising in the heat?
27. Do you or does someone in your family have sickle cell trait or disease?
28. Have you ever had or do you have any problems with your eyes or vision (not including
点
nearsighted needing glasses or contact lens)?

i
29. Do you worry about your weight?
30. Are you on a special diet or do you avoid certain types of foods or food groups?
31. Have you ever had an eating disorder?

Explain “yes” answers for Medical Questions 20-31 here.

MENSTRUAL QUESTIONS YES NO

32. Have you ever had a menstrual period?
33. How old were you when you had your first menstrual period?
34. When was your most recent menstrual period?
35. How many periods have you had in the past 12 months? 91128
If #35 is less than 9, please explain here.

COVID 19 QUESTION
1. Have you tested positive for COVID-19 in the past 30 days? Date of positive test ____________________
o No confirmed COVID-19 infection in the past 30 days.
o Yes, I have tested positive for COVID in the past 30 days.
o Illness was asymptomatic.
o Illness was mild to moderate and managed at home. No cardiovascular symptoms* were experienced
during illness or after recovery of illness.
o Illness was moderate and managed at home. Cardiovascular symptoms* were experienced during
illness or after recovery of illness.
o Illness was severe with necessary hospitalization and/or have ongoing cardiovascular symptoms*.

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 3
 2. If you have tested positive for COVID-19 in the past 30 days, have you engaged in physical activity since
recovering?
o No, I have not been exercising since recovering from COVID-19
o Yes, I have been exercising since recovering from COVID-19.
o I have not experienced cardiovascular symptoms* during exercising
o I have experienced cardiovascular symptoms* during exercising.
3. Have you ever had a prior COVID-19 illness (no matter how long ago) that was severe resulting in hospitalization
and/or prolonged cardiovascular symptoms*?
o No, I have not.
o Yes, I have. Date of illness___________________. Please explain details below.

*Cardiovascular symptoms referred to for COVID 19 Question include chest pain, shortness of breath, exercise
intolerance, heart palpitations. If cardiovascular symptoms were experienced, please explain/list below and provide
current condition.

If you have further comments or information you would like to disclose, please address below or attach additional
page.

By signing below, I hereby state I have completed this questionnaire accurately to the best of my ability and knowledge. I
certify there are no illnesses, injuries or conditions, current or previous, that I have incurred, other than those I have listed
on the preceding pages.

Chuyue Jiang Chuyne Jiang

Athlete Name: ____________________________ Signature: _____________________________ Date: ______________
10 07 2024
(If athlete is under 18 at time ofFeng ling Cao
completing this form) Fengling Cao
Name of Parent/Guardian: ________________________ Signature: _______________________ Date: _____________
10 07 2024
For Medical Provider (MD, DO, PA, NP) Use ONLY
Is further assessment is needed for any of the questions and answers on pages 1-4?
o No, further assessment is not needed. No concerns with the questions/answers on pages 1-4 at this time.
o Yes, further assessment is needed. Please explain below.
Additional comments:

By signing this Health History Questionnaire, I verify I have reviewed all answers and assessed the individual
for all questions answered “yes”.
Provider Name: _____________________________________________ License # ___________________________
Provider Signature: ___________________________________________ Date: ___________________________

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 4
 UC Irvine Club Sports
PHYSICAL EXAMINATION
Name ___________________________________________ Date of Birth _________________________
Year in School __________________ Sport(s) ___________________________________________________
For Medical Provider Use ONLY
EXAMINATION – MUST COMPLETE ALL
Height: Weight: BMI: BP: / Pulse:
Vision: R 20/ L 20/ B 20/ Currently Corrected: □ Y □ N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus
excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve
prolapse [MVP], & aortic insufficiency)
Eyes, ears, nose, and throat
• Pupils equal
• Hearing
Lymph nodes
Heart
• Murmurs (auscultation standing, auscultation supine, and + Valsalva
maneuver)
Pulses
Lungs
Abdomen
Skin
• Herpes simplex virus (HSV), lesions suggestive of methicillin-
resistant Staphylococcus aureus (MRSA), or tinea corporis
Neurological
MD, DO, PA, NP comments regarding abnormal findings:

MUSCULOSKELTAL - MUST COMPLETE ALL 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
MD, DO, PA, NP comments regarding abnormal findings:

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 5
MEDICAL ELIGIBILITY STATEMENT

By signing below, I attest I have reviewed the health history questionnaire, assessed the student for all
questions selected “yes”, and performed a physical examination. It is my professional opinion, this individual
is:

o Medically eligible for all sports without restriction

o Medically eligible for sports with restriction (please explain below)
o Medically eligible for sports with recommendations for further evaluation or treatment of (please
explain below)
o NOT medically eligible for sports at this time. Further evaluation or treatment required (please
explain below)
o NOT medically eligible for sports (please explain below)

Notes regarding eligibility:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medical Provider: _______________________________ MD, DO, PA, NP Date: ________________
Signature: ________________________________________ Clinic/Clinician Stamp
License #: ________________________________________
Address: _________________________________________
_________________________________________________
Phone: ___________________________________________

Adapted from PPE5 Monograph 2019 by AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM 6