Preparticipation Physical Examination Questionnaire Form
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1Preparticipation Physical Examination Questionnaire
HEALTH HISTORY
Name__________________________________________________________
Sex
M / F
Age ____________ Date of Birth ____________________
Address ________________________________________________________
Grade ___________ School _____________________________________
________________________________________________________
School Sports _________________ _______________ ______________
(Fall)
(Winter)
(Spring)
IN CASE OF EMERGENCY, CONTACT:
Name _____________________________________________ Relationship _____________________________
(Parent Information)
Home Phone _______________________________________ Work Phone ______________________________
Mobile Phone_______________________________________ Beeper __________________________________
Personal Physician’s Name ______________________________ Address ____________________________________________ Phone _______________
YES NO
1.
Have you had a medical illness or injury since your last check
30. Have you ever had any problem with your eyes or vision?
up or sports physical?
31. Have you ever had dental health problems?
2.
Have you ever been hospitalized overnight?
32. Have you broken or fractured any bones or dislocated any
3.
Have you ever had surgery?
joints, or been diagnosed with a stress fracture?
4.
Are you currently taking any prescription or nonprescription
33. Have you ever had a sprain, strain, or swelling after injury or
(over the counter) medications or pills or using an inhaler?
any other problems with pain or swelling in muscles, tendons,
5.
Have you ever taken any supplements or vitamins to help you
bones, or joints that has kept you from participating in sports?
improve your performance?
If yes, check appropriate box and explain below.
6.
Do you have any allergies (for example, to pollen, medicine,
Head
Elbow
Hip
food, or stinging insects)?
Neck
Forearm
Thigh
7.
Have you ever had a rash or hives develop during or after
Back
Wrist
Knee
exercise?
Chest
Hand
Shin/Calf
8.
Have you ever been dizzy or passed out during or after
Shoulder
Finger
Ankle
exercise?
Upper Arm
Foot
9.
Have you ever had chest pain during or after exercise?
FEMALES ONLY
10. Have you ever had high blood sugar (diabetes)?
34. Has there been a recent change in menstrual patterns?
11. Have you ever been diagnosed with anemia?
35. At what age did you experience your first menstrual period?
12. Have you ever had racing of your heart or skipped heartbeats?
___________
13. Have you had high blood pressure?
36. When was your most recent menstrual period? ___/___/___
14. Have you ever been told you have a heart murmur?
37. How much time do you usually have from the start of one
15. Has any family member or relative died of heart problems or of
period to the start of another? ________________________
sudden death before age 50?
38. How many periods have you had in the last year? ________
16. Have you had a severe viral infection?
39. What was the longest time between periods in the last year?
17. Has a physician ever denied or restricted your participation in
___________________
sports for any heart problems?
Explain “Yes” Answers Here (Identify each answer with
18. Have you ever been diagnosed with blood or bleeding
question number)
disorders?
19. Have you ever had a kidney or bladder problem (absence of a
paired organ)?
___________________________________________________
20. Have you ever had a head injury or concussion?
21. Have you ever been knocked out, become unconscious, or
___________________________________________________
lost your memory?
___________________________________________________
22. Have you ever had a seizure or convulsion?
___________________________________________________
23. Do you have frequent or severe headaches?
___________________________________________________
24. Do you cough, wheeze, or have trouble breathing during or
___________________________________________________
after activity that prevents you from playing?
25. Do you have asthma or lung disease?
___________________________________________________
26. Do you have seasonal allergies that require medical
___________________________________________________
treatment?
27. Do you use any special protective or corrective equipment or
devices that aren’t usually used for your sport or position (for
example, knee brace, foot orthotics, retainer on your teeth,
hearing aid?
28. Have you ever had any problem with your ears or hearing?
29. Do you tire more easily than you feel you should?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Athlete
Signature of Parent/Guardian
DATE______________
Revised 10/02
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