Pre-Participation Health Examination Form, Updated July, 2014

PRE-PARTICIPATION EXAMINATION FORM .

Instructions for completing pre-participation (athletic)

Health Examination and Consent Form

COMPLETING THIS FORM:

1. PLEASE TYPE OR PRINT LEGIBLY
2. Parent/Guardian along with the student are to complete the Health History on page 3 and the
Disclosure and Consent Document on page 2. Please note student and parent are to sign both
forms. The Health History is to be taken to the physical examination for the
physician/provider to review.
3. Physician/Provider is to complete and sign the Physical Examination form on page 4.
4. Entire completed form is to be returned to school administration.

SUBMITTING THIS FORM:

1. School personnel should review form to assure it is completed properly.
2. ORIGINAL copy is to be retained in school files.

A health examination must be performed annually and the Pre-participation Physical Evaluation
Form must be completed before any student may participate in athletic activities sponsored by this
Association. A Pre-participation Physical Evaluation Form along with the Disclosure and Consent
Document must be on file at the school before any participation in athletic activities.

The health examination may be completed and the form signed by any Medical Doctor (MD),
Doctor of Osteopathy (DO), Physician’s Assistant (PAC), Chiropractic Physician (DC), or Registered
Nurse Practitioner (RNP) functioning within the legal scope of their practice.

THE UTAH HIGH SCHOOL ACTIVITIES ASSOCIATION DOES NOT PROVIDE PRINTED
COPIES OF THIS FORM. PLEASE MAKE ALL NECESSARY COPIES.

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Pre-Participation Health Examination Form, Updated July, 2014

Participant & Parental Disclosure and Consent Document

PLEASE NOTE: It is the responsibility of the parent/guardian to notify the school if there are any unique
individual problems that are not listed on the Pre-participation Physical Evaluation Form.

____________________________________________ ___________________________________________
Name of Student School

Is the student covered by health/accident insurance? Yes No

____________________________________________________
Name of health insurance provider
If no insurance provider, explain ___________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

CONSENT FORM
Parent or Guardian Statement of Permission, Approval, and Acknowledgement:
By signing below, I the parent or legal guardian of the above named student do:
 Hereby consent to the above named student participating in the interscholastic athletic program at the
school listed above. This consent includes travel to and from athletic contests and practice sessions.
 Further consent to treatment deemed necessary by health care providers designated by school
authorities for any illness or injury resulting from his/her athletic participation.
 Recognize that a risk of possible injury is inherent in all sports participation. I further realize that
potential injuries may be severe in nature including such conditions as: fractures, brain injuries,
paralysis or even death.
 Acknowledge and give consent that a copy of this form will remain in the student’s school. I agree that
if my student’s health changes and would alter this evaluation, I will notify the school as soon as
possible but within no longer than 10 days.
 Hereby acknowledge having received education including receiving written information regarding the
signs, symptoms, and risks of sport related concussion. I also acknowledge that I have read,
understand and agree to abide by the UHSAA Concussion Management Policy and/or the policy of the
school listed above. http://www.uhsaa.org/SportsMed/ConcussionManagementPlan.pdf
_____________________________________ _________________________________________
Parent or Guardian Name Parent or Guardian Signature
__________________________
Date

Student Statement
By signing below I acknowledge:
 This application to compete in interscholastic athletics for the above school is entirely voluntary on my
part and is made with the understanding that I have not violated any of the eligibility rules and
regulations of the Utah High School Activities Association.
 My responsibility to report to my coaches and parent(s)/guardian(s) illness or injury I experience.
 Having received education including receiving written information regarding signs, symptoms, and
risks of sport related concussion. I also acknowledge my responsibility to report to my coaches and
parent(s)/guardian(s) any signs or symptoms of a concussion.
_________________________________________ ________________________________
Signature of Student Date

THIS FORM MUST BE ON FILE AT THE MEMBER HIGH SCHOOL PRIOR TO PARTICIPATION.

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■■ Preparticipation Physical Evaluation 
HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam ____________________________________________________________________________________________________________________

Name _ __________________________________________________________________________________ Date of birth ___________________________
Sex ________ Age _ __________ Grade ______________ School ______________________________ Sport(s) ___________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?     Yes    No  If yes, please identify specific allergy below.
  Medicines   Pollens   Food   Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No
1. Has a doctor ever denied or restricted your participation in sports for 26. Do you cough, wheeze, or have difficulty breathing during or
any reason? after exercise?
2. Do you have any ongoing medical conditions? If so, please identify 27. Have you ever used an inhaler or taken asthma medicine?
below:   Asthma    Anemia    Diabetes    Infections 28. Is there anyone in your family who has asthma?
Other: ________________________________________________ 29. Were you born without or are you missing a kidney, an eye, a testicle
3. Have you ever spent the night in the hospital? (males), your spleen, or any other organ?
4. Have you ever had surgery? 30. Do you have groin pain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or 32. Do you have any rashes, pressure sores, or other skin problems?
AFTER exercise? 33. Have you had a herpes or MRSA skin infection?
6. Have you ever had discomfort, pain, tightness, or pressure in your 34. Have you ever had a head injury or concussion?
chest during exercise?
35. Have you ever had a hit or blow to the head that caused confusion,
7. Does your heart ever race or skip beats (irregular beats) during exercise? prolonged headache, or memory problems?
8. Has a doctor ever told you that you have any heart problems? If so, 36. Do you have a history of seizure disorder?
check all that apply:
  High blood pressure   A heart murmur 37. Do you have headaches with exercise?
  High cholesterol   A heart infection 38. Have you ever had numbness, tingling, or weakness in your arms or
  Kawasaki disease Other: ______________________ legs after being hit or falling?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, 39. Have you ever been unable to move your arms or legs after being hit
echocardiogram) or falling?
10. Do you get lightheaded or feel more short of breath than expected 40. Have you ever become ill while exercising in the heat?
during exercise? 41. Do you get frequent muscle cramps when exercising?
11. Have you ever had an unexplained seizure? 42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends 43. Have you had any problems with your eyes or vision?
during exercise?
44. Have you had any eye injuries?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
45. Do you wear glasses or contact lenses?
13. Has any family member or relative died of heart problems or had an
46. Do you wear protective eyewear, such as goggles or a face shield?
unexpected or unexplained sudden death before age 50 (including
drowning, unexplained car accident, or sudden infant death syndrome)? 47. Do you worry about your weight?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan 48. Are you trying to or has anyone recommended that you gain or
syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT lose weight?
syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic 49. Are you on a special diet or do you avoid certain types of foods?
polymorphic ventricular tachycardia?
50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator? 51. Do you have any concerns that you would like to discuss with a doctor?

16. Has anyone in your family had unexplained fainting, unexplained FEMALES ONLY
seizures, or near drowning? 52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS Yes No 53. How old were you when you had your first menstrual period?
17. Have you ever had an injury to a bone, muscle, ligament, or tendon 54. How many periods have you had in the last 12 months?
that caused you to miss a practice or a game?
Explain “yes” answers here
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan,
­injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?

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______________________

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503 9-2681/0410
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■■ Preparticipation Physical Evaluation 
PHYSICAL EXAMINATION FORM
Name _ __________________________________________________________________________________ Date of birth ___________________________
PHYSICIAN REMINDERS
1.  Consider additional questions on more sensitive issues
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2.  Consider reviewing questions on cardiovascular symptoms (questions 5–14).

EXAMINATION
Height Weight   Male   Female
BP / ( / ) Pulse Vision R 20/ L 20/ Corrected    Y    N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/ears/nose/throat
• Pupils equal
• Hearing
Lymph nodes
Heart a
• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)
Pulses
• Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
• HSV, lesions suggestive of MRSA, tinea corporis
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
• Duck-walk, single leg hop
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
a

Consider GU exam if in private setting. Having third party present is recommended.

b

Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

c

 Cleared for all sports without restriction

 Cleared for all sports without restriction with recommendations for further evaluation or treatment for __________________________________________________________________
_____________________________________________________________________________________________________________________________________________
 Not cleared
Pending further evaluation
 
For any sports
 
For certain sports ______________________________________________________________________________________________________________________
 
Reason ____________________________________________________________________________________________________________________________
Recommendations __________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and
participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If condi-
tions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely
explained to the athlete (and parents/guardians).

Name of physician (print/type) _____________________________________________________________________________________________________ Date ________________

Address ___________________________________________________________________________________________________________ Phone _________________________

Signature of physician _______________________________________________________________________________________________________________________,

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic
Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
HE0503 9-2681/0410
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