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EL2

Florida High School Athletic Association

Revised 05/16

Preparticipation Physical Evaluation

(Page 1 of 3)

This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.

This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.

Part 1. Student Information

(to be completed by student or parent)

Student’s Name: ________________________________________________________________________ Sex: _____ Age: _____ Date of Birth: _____/ _____/ _____

School: ____________________________________________________ Grade in School: _____ Sport(s): ________________________________________________

Home Address: _______________________________________________________________________________________ Home Phone: ( _____) _______________

Name of Parent/Guardian: _______________________________________________________________ E-mail: ___________________________________________

Person to Contact in Case of Emergency: _____________________________________________________________________________________________________

Relationship to Student: _______________________ Home Phone: ( _____) ______________ Work Phone: ( _____) _____________ Cell Phone: ( _____) _____________

Personal/Family Physician: ___________________________________________City/State: ___________________________ Office Phone: ( _____) _____________

Part 2. Medical History

(to be completed by student or parent). Explain “yes” answers below. Circle questions you don’t know answers to.

Yes

1. Have you had a medical illness or injury since your last ____ ____

26. Have you ever become ill from exercising in the heat?

____ ____

check up or sports physical?

27. Do you cough, wheeze or have trouble breathing during or after

____ ____

2. Do you have an ongoing chronic illness?

____ ____

activity?

28. Do you have asthma?

____ ____

3. Have you ever been hospitalized overnight?

____ ____

4. Have you ever had surgery?

____ ____

29. Do you have seasonal allergies that require medical treatment?

____ ____

5. Are you currently taking any prescription or non-

____ ____

30. Do you use any special protective or corrective equipment or

____ ____

prescription (over-the-counter) medications or pills or

medical devices that aren’t usually used for your sport or position

using an inhaler?

(for example, knee brace, special neck roll, foot orthotics, shunt,

retainer on your teeth or hearing aid)?

6. Have you ever taken any supplements or vitamins to

____ ____

help you gain or lose weight or improve your

31. Have you had any problems with your eyes or vision?

____ ____

performance?

32. Do you wear glasses, contacts or protective eyewear?

____ ____

7. Do you have any allergies (for example, pollen, latex,

____ ____

33. Have you ever had a sprain, strain or swelling after injury?

____ ____

medicine, food or stinging insects)?

34. Have you broken or fractured any bones or dislocated any joints?

____ ____

8. Have you ever had a rash or hives develop during or

____ ____

35. Have you had any other problems with pain or swelling in muscles,

____ ____

after exercise?

tendons, bones or joints?

9. Have you ever passed out during or after exercise?

____ ____

If yes, check appropriate blank and explain below:

10. Have you ever been dizzy during or after exercise?

____ ____

___ Head

___ Elbow

___ Hip

11. Have you ever had chest pain during or after exercise?

____ ____

___ Neck

___ Forearm

___ Thigh

12. Do you get tired more quickly than your friends do

____ ____

___ Back

___ Wrist

___ Knee

during exercise?

___ Chest

___ Hand

___ Shin/Calf

13. Have you ever had racing of your heart or skipped

____ ____

___ Shoulder

___ Finger

___ Ankle

heartbeats?

___ Upper Arm

___ Foot

14. Have you had high blood pressure or high cholesterol?

____ ____

36. Do you want to weigh more or less than you do now?

____ ____

15. Have you ever been told you have a heart murmur?

____ ____

37. Do you lose weight regularly to meet weight requirements for your

____ ____

16. Has any family member or relative died of heart

____ ____

sport?

problems or sudden death before age 50?

38. Do you feel stressed out?

____ ____

17. Have you had a severe viral infection (for example,

____ ____

39. Have you ever been diagnosed with sickle cell anemia?

____ ____

myocarditis or mononucleosis) within the last month?

40. Have you ever been diagnosed with having the sickle cell trait?

____ ____

18. Has a physician ever denied or restricted your

____ ____

41. Record the dates of your most recent immunizations (shots) for:

participation in sports for any heart problems?

Tetanus: _______________

Measles: _______________

19. Do you have any current skin problems (for example,

____ ____

Hepatitus B: ____________

Chickenpox: ____________

itching, rashes, acne, warts, fungus, blisters or pressure sores)?

20. Have you ever had a head injury or concussion?

____ ____

FEMALES ONLY (optional)

21. Have you ever been knocked out, become unconscious

____ ____

42. When was your first menstrual period? _______________________

or lost your memory?

43. When was your most recent menstrual period? _________________

22. Have you ever had a seizure?

____ ____

44. How much time do you usually have from the start of one period to

23. Do you have frequent or severe headaches?

____ ____

the start of another? _______________________________________

24. Have you ever had numbness or tingling in your arms,

____ ____

45. How many periods have you had in the last year? _______________

hands, legs or feet?

46. What was the longest time between periods in the last year? ________

25. Have you ever had a stinger, burner or pinched nerve?

____ ____

Explain “Yes” answers here: _______________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida

Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic

tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.

Signature of Student: _____________________________________ Date: ____/ ____/ ____ Signature of Parent/Guardian: __________________________________ Date: ____/ ____/ ____

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Form El2 - Preparticipation Physical Evaluation - Florida High School Athletic Association

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