PREPARTICIPATION PHYSICAL EVALUATION (Page 1 of 4)

This medical history form should be retained by the healthcare provider and/or parent. EL2
This form is valid for 365 calendar days from the date signed below.
Revised 4/24
MEDICAL HISTORY FORM
Student Information (to be completed by student and parent) print legibly
Student’s Full Name: __________________________________________________ Biological Sex: _____ Age: _____ Date of Birth: ___ /___ /_____
School: ________________________________________________________ Grade in School: _____ Sport(s): _______________________________
Home Address: _________________________________ City/State: ____________________ Home Phone: (_____) __________________________
Name of Parent/Guardian: _______________________________________ E-mail: _____________________________________________________
Person to Contact in Case of Emergency: ___________________________ Relationship to Student: _______________________________________
Emergency Contact Cell Phone: (_____) _________________ Work Phone: (_____) _________________ Other Phone: (_____) _________________
Family Healthcare Provider: ____________________________ City/State: ________________________ Office Phone: (_____) _________________

List past and current medical conditions:

__________________________________________________________________________________________
Have you ever had surgery? If yes, please list all surgical procedures and dates:
__________________________________________________________________________________________
Medicines and supplements (please list all current prescription medications, over-the-counter medicines, and supplements (herbal and nutritional):
__________________________________________________________________________________________
Do you have any allergies? If yes, please list all of your allergies (i.e., medicines, pollens, food, insects):
__________________________________________________________________________________________
Patient Health Questionaire version 4 (PHQ-4)
Over the past two weeks, how often have you been bothered by any of the following problems? (Circle response)

Not at all Several days Over half of the days Nearly everyday

Feeling nervous, anxious,

0 1 2 3
or on edge
Not being able to stop or
0 1 2 3
control worrying
Little interest or pleasure
0 1 2 3
in doing things
Feeling down, depressed,
0 1 2 3
or hopeless

GENERAL QUESTIONS HEART HEALTH QUESTIONS ABOUT YOU

Explain “Yes” answers at the end of this form. Yes No (continued) Yes No
Circle questions if you don’t know the answer.

Do you have any concerns that you would like to discuss with Has a doctor ever requested a test for your heart? For
1 your provider? 8 example, electrocardiography (ECG) or echocardiography
(ECHO)?
Has a provider ever denied or restricted your participation in Do you get light-headed or feel shorter of breath than your
2 sports for any reason? 9 friends during exercise?

3 Do you have any ongoing medical issues or recent illnesses? 10 Have you ever had a seizure?

HEART HEALTH QUESTIONS ABOUT YOU Yes No HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
Has any family member or relative died of heart problems or
Have you ever passed out or nearly passed out during or after
4 exercise?
11 had an unexpected or unexplained sudden death before age
35? (including drowning or unexplained car crash)

Does anyone in your family have a genetic heart problem such

Have you ever had discomfort, pain, tightness, or pressure in
5 your chest during exercise?
as hypertrophic cardiomyopathy (HCM), Marfan Syndrome,
arrhythmogenic right ventricular cardiomyopathy (ARVC),
12 long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada
Does your heart ever race, flutter in your chest, or skip beats syndrome, or catecholaminerigc polymorphic ventricular
6 (irregular beats) during exercise? tachycardia (CPVT)?

Has anyone in your family had a pacemaker or an implanted

7 Has a doctor ever told you that you have any heart problems? 13 defibrillator before age 35?

This form is not considered valid unless all sections are complete.
 PREPARTICIPATION PHYSICAL EVALUATION (Page 2 of 4)
This medical history form should be retained by the healthcare provider and/or parent. EL2
This form is valid for 365 calendar days from the date signed below.
Revised 4/24

Student’s Full Name: _____________________________________________ Date of Birth: ___ /___ /_____ School: __________________________

BONE AND JOINT QUESTIONS Yes No MEDICAL QUESTIONS (continued) Yes No

14 Have you ever had a stress fracture? 26 Do you worry about your weight?

Did you ever injure a bone, muscle, ligament, joint, or tendon Are you trying to or has anyone recommended that you gain
15 that caused you to miss a practice or game? 27 or lose weight?

Do you have a bone, muscle, ligament, or joint injury that Are you on a special diet or do you avoid certain types of
16 currently bothers you? 28 foods or food groups?

MEDICAL QUESTIONS Yes No 29 Have you ever had an eating disorder?

Do you cough, wheeze, or have difficulty breathing during Explain “Yes” answers here:
17 or after exercise or has a provider ever diagnosed you with
asthma?
________________________________________________________
Are you missing a kidney, an eye, a testicle, your spleen, or any
18 other organ?
________________________________________________________
Do you have groin or testicle pain or a painful bulge or hernia
19 in the groin area?
________________________________________________________
Do you have any recurring skin rashes or rashes that come and
20 go, including herpes or methicillin-resistant staphylococcus
aureus (MRSA)? ________________________________________________________
Have you had a concussion or head injury that caused
21 confusion, a prolonged headache, or memory problems? ________________________________________________________
Have you ever had numbness, had tingling, had weakness in
________________________________________________________
22 your arms or legs, or been unable to move your arms or legs
after being hit or falling?
________________________________________________________
23 Have you ever become ill while exercising in the heat?

24
Do you or does someone in your family have sickle cell trait ________________________________________________________
or disease?
Have you ever had or do you have any problems with your ________________________________________________________
25 eyes or vision?

This form is not considered valid unless all sections are complete.

Participation in high school sports is not without risk. The student-athlete and parent/guardian acknowledge truthful answers to the
above questions allows for a trained clinician to assess the individual student-athlete against risk factors associated with sports-related
injuries and death. Florida Statute 1006.20 requires a student candidate for an interscholastic athletic team to successfully complete a
preparticipation physical evaluation as the first step of injury prevention. This preparticipation physical evaluation shall be completed
each year before participating in interscholastic athletic competition or engaging in any practice, tryout, workout, conditioning, or
other physical activity, including activities that occur outside of the school year.

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 physical evaluation required by Florida Statute 1006.20, 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 (ECG), echocardiogram (ECHO), and/or cardio stress test. The FHSAA Sports Medicine Advisory Committee strongly
recommends a medical evaluation with your healthcare provider for risk factors of sudden cardiac arrest which may include the special
tests listed above.

Student-Athlete Name: _________________________ (printed) Student-Athlete Signature: ____________________________ Date: ___ / ___ / ___

Parent/Guardian Name: ________________________ (printed) Parent/Guardian Signature: ___________________________ Date: ___ / ___ / ___

Parent/Guardian Name: ________________________ (printed) Parent/Guardian Signature: ___________________________ Date: ___ / ___ / ___

Modified from © 2019 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.
 PREPARTICIPATION PHYSICAL EVALUATION (Page 3 of 4)
This medical history form should be retained by the healthcare provider and/or parent. EL2
This form is valid for 365 calendar days from the date signed below.
Revised 4/24
PHYSICAL EXAMINATION FORM
Student’s Full Name: _____________________________________________ Date of Birth: ___ /___ /_____ School: __________________________
HEALTHCARE PROFESSIONAL REMINDERS:
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? • During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Have you ever taken anabolic steroids or used any other performance-enhancing
• Do you drink alcohol or use any other drugs?
supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your • Have you experienced performance changes, felt fatigued, and/or experienced times
performance? of low energy during the past year?

Verify completion of FHSAA EL2 Medical History (pages 1 and 2), review these medical history responses as part of your assessment.
Cardiovascular history/symptom questions include Q4-Q13 of Medical History form. (check box if complete)
EXAMINATION
Height: Weight:
BP: / ( / ) Pulse: Vision: R 20/ L 20/ Corrected: Yes No
MEDICAL - healthcare professional shall initial each assessment NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyl, 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 - healthcare professional shall initial each assessment 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

This form is not considered valid unless all sections are complete.
*Consider electrocardiography (ECG), echocardiography (ECHO), referral to a cardiologist for abnormal cardiac history or examination findings, or any combination thereof. The FHSAA Sports Medicine
Advisory Committee strongly recommends to a student-athlete (parent), a medical evaluation with your healthcare provider for risk factors of sudden cardiac arrest which may include an electrocardiogram.

Name of Healthcare Professional (print or type): _____________________________________________________ Date of Exam: ___ / ___ / ______
Address: ____________________________________ Phone: (_____) _________________ E-mail: ________________________________________
Signature of Healthcare Professional: _______________________________________ Credentials: ______________ License #: _________________
Modified from © 2019 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.
 PREPARTICIPATION PHYSICAL EVALUATION (Page 4 of 4)
SUBMIT THIS MEDICAL ELIGIBILITY FORM TO THE SCHOOL EL2
This form is valid for 365 calendar days from the date signed below.
Revised 4/24
MEDICAL ELIGIBILITY FORM
Student Information (to be completed by student and parent) print legibly
Student’s Full Name: __________________________________________________ Biological Sex: _____ Age: _____ Date of Birth: ___ /___ /_____
School: ________________________________________________________ Grade in School: _____ Sport(s): _______________________________
Home Address: _________________________________ City/State: ____________________ Home Phone: (_____) __________________________
Name of Parent/Guardian: _______________________________________ E-mail: _____________________________________________________
Person to Contact in Case of Emergency: ___________________________ Relationship to Student: _______________________________________
Emergency Contact Cell Phone: (_____) _________________ Work Phone: (_____) _________________ Other Phone: (_____) _________________
Family Healthcare Provider: ____________________________ City/State: ________________________ Office Phone: (_____) _________________

The preparticipation physical evaluation must be administered by a practitioner licensed under Florida chapter 458, chapter 459, chapter 460,
§464.012, or registered under §464.0123, and in good standing with the practitioner’s regulatory board. (§1006.20(2)(c), F.S.)
Medically eligible for all sports without restriction
Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of: (use additional sheet, if necessary)
_______________________________________________________________________________________________________________________________________
Medically eligible for only certain sports as listed below:
_______________________________________________________________________________________________________________________________________
Not medically eligible for any sports
Recommendations: (use additional sheet, if necessary)
_______________________________________________________________________________________________________________________________________

I hereby certify that I, or a clinician under my direct supervision, have examined the above-named student-athlete using the FHSAA EL2 Preparticipation
Physical Evaluation and have provided the conclusion(s) listed above. A copy of the exam has been retained and can be accessed by the parent as
requested. Any injury or other medical conditions that arise after the date of this medical clearance should be properly evaluated, diagnosed, and
treated by an appropriate healthcare professional prior to participation in activities.
Name of Healthcare Professional (print or type): _____________________________________________________ Date of Exam: ___ / ___ / ______
Address: __________________________________________________________________________________ Phone: (_____) _________________
Signature of Healthcare Professional: _______________________________________ Credentials: ______________ License #: _________________

SHARED EMERGENCY INFORMATION - completed at the time of assessment by practitioner and parent

Check this box if there is no relevant medical history to share related to Provider Stamp (if required by school)
participation in competitive sports.

Medications: (use additional sheet, if necessary)

List: ____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Relevant medical history to be reviewed by athletic trainer/team physician: (explain below, use additional sheet, if necessary)
Allergies Asthma Cardiac/Heart Concussion Diabetes Heat Illness Orthopedic Surgical History Sickle Cell Trait Other
Explain: _________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Signature of Student: _____________________________ Date: ___/___/___ Signature of Parent/Guardian:________________________________ Date: ___/___/___

We hereby state, to the best of our knowledge the information recorded on this form is complete and correct. 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 (ECG), echocardiogram (ECHO),
and/or cardio stress test.

This form is not considered valid unless all sections are complete.

Modified from © 2019 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.
 PREPARTICIPATION PHYSICAL EVALUATION (Supplement)
SUBMIT THIS MEDICAL ELIGIBILITY FORM TO THE SCHOOL EL2
This form is valid for 365 calendar days from the date signed below.
Revised 4/24
This form is only used, or requested, if a student-athlete has been referred for additional evaluation, prior to full medical clearance.
MEDICAL ELIGIBILITY FORM - Referred Provider Form
Student Information (to be completed by student and parent) print legibly
Student’s Full Name: __________________________________________________ Biological Sex: _____ Age: _____ Date of Birth: ___ /___ /_____
School: ________________________________________________________ Grade in School: _____ Sport(s): _______________________________
Home Address: _________________________________ City/State: ____________________ Home Phone: (_____) __________________________
Name of Parent/Guardian: _______________________________________ E-mail: _____________________________________________________
Person to Contact in Case of Emergency: ___________________________ Relationship to Student: _______________________________________
Emergency Contact Cell Phone: (_____) _________________ Work Phone: (_____) _________________ Other Phone: (_____) _________________
Family Healthcare Provider: ____________________________ City/State: ________________________ Office Phone: (_____) _________________

Referred for: ___________________________________________________ Diagnosis: _________________________________________________

I hereby certify the evaluation and assessment for which this student-athlete was referred has been conducted by myself or a clinician under my direct supervision with
the conclusions documented below:

Medically eligible for all sports without restriction as of the date signed below
Medically eligible for all sports without restriction after completion of the following treatment plan: (use additional sheet, if necessary)
_______________________________________________________________________________________________________________________________________
Medically eligible for only certain sports as listed below:
_______________________________________________________________________________________________________________________________________
Not medically eligible for any sports
Further Recommendations: (use additional sheet, if necessary)
_______________________________________________________________________________________________________________________________________

Name of Healthcare Professional (print or type): _____________________________________________________ Date of Exam: ___ / ___ / ______
Address: __________________________________________________________________________________ Phone: (_____) _________________
Signature of Healthcare Professional: _______________________________________ Credentials: ______________ License #: _________________

Provider Stamp (if required by school)