Sport: MB WB
BB
SB
Shelton State Community College
Pre-participation Physical Evaluation
C
Name: ___________________________________ Gender: ____ Age: _______ DOB: ___________________
Address: ______________________________________________ Cell phone: __________________________
______________________________________________
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Have you ever been hospitalized?
Have you ever had surgery?
Are you presently taking any medications or pills?
Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Do you tire more quickly than your teammates during exercise?
Have you ever had high blood pressure?
Have you ever been told that you have a heart murmur?
Have you ever had racing of your heart or skipped heart beats?
Has anyone in your family died of heart problems or a sudden death before age 50?
Do you have any skin problems?
Have you ever had a head injury?
Have you ever been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had stinger, burner, or pinched nerve?
Have you ever had heat or muscle cramps?
Have you ever been dizzy or passed out due to heat?
Does anyone in your family have sickle cell anemia/trait?
Do you have trouble breathing or do you cough during or after activity?
Do you require the use of an inhaler?
Do you use any special equipment? (pads, braces, mouth guards, etc)
Have you had any problems with your eyes or vision?
Do you wear glasses/contacts or protective eye wear?
Do you have any allergies? (peanuts, bee stings, etc)
Have you had any other medical problems? (Mononucleosis, diabetes, MRSA, etc)
Have you had a medical problem or injury since your last evaluation?
Have you ever sprained/strained, dislocated, fractured, or had repeated swelling or
other injuries of any bones or joints?
Yes
No
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Explain ‘Yes’ answers here please: ______________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Females only:
1. When was your first menstrual period? ___________________________________________________________
2. When was your last menstrual period? ____________________________________________________________
3. What was the longest time between your periods this last year? _______________________________________
I hereby state, to the best of my knowledge, all answers to the above questions are correct.
________________________________________________________________
Signature of Student-Athlete
__________________________
Date
Physical Examination:
Height: _______________
Weight: ________________ BP: ________ /_________
Vision: R
L
20/ ________
Musculoskeletal:
20/________
corrected? Y
Pulse: ____________
N
Normal?
Abnormal findings?
Normal?
Abnormal findings?
Neck
Shoulder
Elbow
Wrist
Hand/Finger
Back
Hip
Knee
Ankle
Foot/Toe
To be completed by physician:
Cardiovascular
Pulses
Heart
Lungs
Skin
E.N.T.
Abdominal
Genitalia (males)
Other
Clearance:
A. Cleared without limitations
B. Cleared after completing evaluation/rehabilitation for: ______________________________________________
C. Not cleared for athletic participation
Due to: ______________________________________________________________________________
Recommendation: _____________________________________________________________________
_____________________________________________________________________________________
Name of Physician: __________________________________________________________________________________
Address: ___________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________
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Signature of Physician
Date