the-pediatric-center.com - SPORTS PHYSICAL FORM

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
Heart • 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 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

Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combination of those.
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PREPARTICIPATION PHYSICAL EVALUATION
MEDICAL ELIGIBILITY FORM
Name:
Date of Birth:

MonthDayYear
Date
Medical eligible for all sports without restrictionMedical eligible for all sports without restriction with recommendations for further evaluation or treatment of
Medical eligible for all certain sports
Not medically eligible pending further evaluationNot medically eligible for any sports
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 are 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).
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SHARED EMERGENCY INFORMATION
Allergies:
Medications:
Other Information:
Emergency contacts:
Should be Empty:

	Not at all (0)	Several days(1)	Over half the days(2)	Nearly every day(3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

	Yes	No
1. Do you have any concerns that you would like to discuss with your provider?
2. Has a provider ever denied or restricted your participation in sports for any reason?
3. Do you have any ongoing medical issues or recent illness?

	Yes	No
4. Have you ever passed out or nearly passed out during or after exercise?
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any heart problems?
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
10. Have you ever had a seizure?

	Yes	No
1 1. 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)?
12. 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 (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly morphic ventricular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

	Yes	No
16. Do you cough, wheeze, or have difficulty breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
22. Have you ever become ill while exercising in the heat?
23. Do you or does someone in your family have sickle cell trait or disease?
24. Have you ever had or do you have any problems with your eyes or vision?
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended that you gain or lose weight?
27. Are you on a special diet or do you avoid certain types of foods or food groups?
28. Have you ever had an eating disorder?

SPORTS PHYSICAL FORM

	Yes	No
14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?

	Yes	No
29. Have you ever had a menstrual period?
30. How old were you when you had your first menstrual period?
31. When was your most recent menstrual period?
32. How many periods have you had in the past 1 2 months?