Pre‐Participation Physical Exam Sport: ________________________________________________ Date:__________________ Personal Information Name:_________________________________ Date Of Birth:__________________________ SS#: ________________ID#: _______________ Age: ____ Sex: M F Athletic Year: Fresh Soph Campus/Local Address: ___________________ Permanent Address: ____________________ _______________________________________ _____________________________________ Campus/Local Phone: ____________________ Permanent Phone: ____________________ Parent Information Father/Guardian:_______________________ Mother/ Guardian:_______________________ Address: _____________________________ Address: _______________________________ Phone: ______________________________ Phone: ________________________________ SS#: ________________________________ SS#: ___________________________________ Employer: ___________________________ Employer: ______________________________ Employer Address: ____________________ Employer Address: _______________________ ____________________________________ _______________________________________ Employer Phone: _____________________ Employer Phone: _________________________ Health Insurance Information Primary Insurance Company Name: ________________________________________________ Address: ______________________________________________________________________ Phone: _______________________________________________________________________ Policy Number: _____________________ Group #: ___________________________________ Are you covered by Medicare/ Medicaid? YES NO Emergency Information Name: _________________________________________ Phone (Primary):________________ Relationship: _________________________________ Phone ( Secondary):_______________ Family Physician Name and Practice of Family Physician: _____________________________________________________________________________ Address of Family Physician: _____________________________________________________ Phone of Family Physician: ____________________________ Date Last Seen: _____________ I hereby state that to the best of my knowledge, the above information is correct. Athlete’s Signature: ________________________________________ Date: _______________ 1 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Family History Have any of your relatives had any of the following? (Please explain in the space provided) Allergies Y N _______________________________________________________ Diabetes Y N _______________________________________________________ Epilepsy Y N _______________________________________________________ Heat Disease Y N _______________________________________________________ High/Low BP Y N _______________________________________________________ Sickle Cell Trait Y N _______________________________________________________ Tuberculosis Y N _______________________________________________________ Personal History Do you now or have you ever had the following: Abnormal bleeding or Clotting disorder Y N _______________________________________________________ Anemia Y N _______________________________________________________ Appendicitis Y N _______________________________________________________ Arthritis Y N _______________________________________________________ Allergies Y N _______________________________________________________ Bone Disease Y N _______________________________________________________ Boils Y N _______________________________________________________ Cancer Y N _______________________________________________________ Chicken Pox Y N _______________________________________________________ Colitis Y N _______________________________________________________ Concussion Y N _______________________________________________________ Diabetes Y N _______________________________________________________ Diphtheria Y N _______________________________________________________ Enlarged Spleen Y N _______________________________________________________ Ruptured Spleen Y N _______________________________________________________ Epilepsy Y N _______________________________________________________ Gall Bladder Y N _______________________________________________________ German Measles Y N _______________________________________________________ GI Tract Infection Y N _______________________________________________________ Gout Y N _______________________________________________________ Hay Fever Y N _______________________________________________________ Hemorrhoids Y N _______________________________________________________ Hepatitis (A,B,C) Y N _______________________________________________________ 2 Revised August 2015 Personal History Cont. Hernia Y N _______________________________________________________ Hypoglycemia Y N _______________________________________________________ Influenza Y N _______________________________________________________ Jaundice Y N _______________________________________________________ Kidney Stone Y N _______________________________________________________ Kidney Disease Y N _______________________________________________________ Liver Disease Y N _______________________________________________________ Lupus Y N _______________________________________________________ Malaria Y N _______________________________________________________ Measles Y N _______________________________________________________ Melanoma Y N _______________________________________________________ Migraines Y N _______________________________________________________ Mononucleosis Y N _______________________________________________________ Mumps Y N _______________________________________________________ Neuralgia Y N _______________________________________________________ Pleurisy Y N _______________________________________________________ Pneumonia Y N _______________________________________________________ Pneumothorax Y N _______________________________________________________ Rheumatic Fever Y N _______________________________________________________ Rheumatism Y N _______________________________________________________ Scarlet Fever Y N _______________________________________________________ Tetanus Shot Y N _______________________________________________________ Thyroid Disease Y N _______________________________________________________ Tuberculosis Y N _______________________________________________________ Ulcer Y N _______________________________________________________ Varicose Veins Y N _______________________________________________________ Y N _______________________________________________________ Whooping Cough Other Y N _______________________________________________________ Have you ever had any of the following symptoms? If YES explain. Blurred Vision Y N _______________________________________________________ Blood in Urine Y N _______________________________________________________ Burning w/ Urination Y N _______________________________________________________ Chest Pain Y N _______________________________________________________ Coughing Blood Y N _______________________________________________________ 3 Revised August 2015 Personal History Cont. Convulsions/Seizures Y N _______________________________________________________ Depression/Anxiety Y N _______________________________________________________ Difficulty w/Urination Y N ______________________________________________________ Dizziness Y N _______________________________________________________ Enlarged Glands Y N _______________________________________________________ Excessive Cramping Y N _______________________________________________________ Excessive Bleeding Y N _______________________________________________________ Eye Injury Y N _______________________________________________________ Y N _______________________________________________________ Fainting Spells Fatigue easily Y N _______________________________________________________ Fluttering Heart Y N _______________________________________________________ Frequent Colds Y N _______________________________________________________ Frequent Constipation Y N ______________________________________________________ Frequent Cough Y N _______________________________________________________ Frequent Diarrhea Y N _______________________________________________________ Frequent Headaches Y N _______________________________________________________ Frequent Nausea Y N _______________________________________________________ Frequent Sore Throat Y N _______________________________________________________ Hallucinations Y N _______________________________________________________ Headache after games Y N ______________________________________________________ Hearing Loss Y N _______________________________________________________ Indigestion Y N _______________________________________________________ Loss if Vision Y N _______________________________________________________ Nose Bleeds Y N _______________________________________________________ Paralysis Y N _______________________________________________________ Shortness of Breath Y N _______________________________________________________ Unconsciousness Y N _______________________________________________________ General: Are the following pair organs intact and normal? Kidneys Y N _______________________________________________________ Lungs Y N _______________________________________________________ Testes (Males only) Y N _______________________________________________________ FEMALES ONLY: Do you currently have or have you ever had the following: Please explain Yes answers. 4 Revised August 2015 Irregular Periods Y N _______________________________________________________ Severe Cramps Y N _______________________________________________________ Injury to the Breast Y N _______________________________________________________ Surgery to the Breast Y N _______________________________________________________ Lumps on the Breast Y N _______________________________________________________ Surgery on ovaries or Uterus Y N _______________________________________________________ Abnormal PAP smear Y N _______________________________________________________ Are you taking birth control medication (pills, patch or injection) Y N If yes please list name of medication: ______________________________________________________________________________ Allergies Are you allergic to any of the following: Please Explain YES answers including: type of reactions, treatment received, control methods, etc. Aspirin Y N _______________________________________________________ Codeine Y N _______________________________________________________ Morphine Y N _______________________________________________________ Cosmetics Y N _______________________________________________________ Antibiotics Y N _______________________________________________________ Any Foods Y N _______________________________________________________ Adhesive Tape Y N _______________________________________________________ Latex Products Y N _______________________________________________________ Anesthesia Y N _______________________________________________________ Bee/Insect Stings Y N _______________________________________________________ Other Medications Y N _______________________________________________________ Other Allergies Y N _______________________________________________________ Neurological Do you currently have or ever have had the following: Please explain YES answers. Concussion Y N _______________________________________________________ Skull Fracture Y N _______________________________________________________ Unconsciousness Y N _______________________________________________________ Hospitalization/ Surgery (Head injury) Y N _______________________________________________________ Hospitalization/ Surgery (Neck injury) Y N _______________________________________________________ Neck Fracture Y N _______________________________________________________ Pinched Nerve Y N _______________________________________________________ 5 Revised August 2015 Neurological Cont. Burner/ Stinger Y N _______________________________________________________ Epilepsy Y N _______________________________________________________ Heat Issues Do you currently have or have you ever had the following: Please explain YES answers. Heat exhaustion Y N _______________________________________________________ Heat Stroke Y N _______________________________________________________ Hospitalization (due to heat illness) Y N _______________________________________________________ Frequent Dehydration Y N ______________________________________________________ Dental Do you currently have or have you ever had the following: Please explain YES answers. Cavities Y N _______________________________________________________ Missing Teeth Y N _______________________________________________________ False Teeth Y N _______________________________________________________ Ear, Nose and Throat Do you currently have or have you ever had the following: Please explain YES answers. Hearing Impairment Y N _______________________________________________________ Ringing in the Ears Y N _______________________________________________________ Frequent ear ache Y N _______________________________________________________ Injury/Surgery to Ear Y N _______________________________________________________ Nose Fracture Y N _______________________________________________________ Frequent Nose Bleeds Y N ______________________________________________________ Frequent Tonsillitis Y N _______________________________________________________ Eye Do you currently have or have you ever had the following: Please explain YES answers. Eye Surgery Y N _______________________________________________________ Vision Problems Y N _______________________________________________________ Glasses (other than reading) Y N _______________________________________________________ Contact Lenses Y N _______________________________________________________ 6 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Athletic Injuries and Surgeries Have you ever had an athletic injury and/or surgery to the following: Shoulder Y N ______________________________________________________ Hand/Wrist Y N _______________________________________________________ Knee Y N _______________________________________________________ Ankle Y N _______________________________________________________ Feet Y N _______________________________________________________ Back Y N _______________________________________________________ Hips Y N _______________________________________________________ Thighs Y N _______________________________________________________ Abdominal Y N _______________________________________________________ Chest Y N _______________________________________________________ Other Y N _______________________________________________________ Orthopedic Screening Neck AB N ______________________________________________________ Spine AB N ______________________________________________________ Shoulders AB N ______________________________________________________ Arms/Hands/Wrists AB N ______________________________________________________ Hips AB N ______________________________________________________ Thighs AB N ______________________________________________________ Knees AB N ______________________________________________________ Neuromuscular AB N ______________________________________________________ Have you ever been hospitalized or had any other surgeries other than what has been mentioned above? Y N If Yes, Explain: ______________________________________________________________________________
______________________________________________________________________________ Are there any other health related problems or questions you have that you would like to discuss with the athletic trainer or a physician? ______________________________________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ _____________________________ _________________________ Physician’s Signature Physician’s Phone 7 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Vital Signs Height: ______________(in) Weight: ________________(lbs) Pulse: ________________(BPM) Blood Pressure: _________/______________ Vision: _____/_______ Glasses /Contacts /NA Medical ENT AB N _____________________________________________________ Eye AB N _____________________________________________________ Head AB N _____________________________________________________ Lungs AB N _____________________________________________________ Chest AB N _____________________________________________________ Heart AB N _____________________________________________________ Spine AB N _____________________________________________________ Abdomen AB N _____________________________________________________ Hernia AB N _____________________________________________________ Skin AB N _____________________________________________________ Testicular AB N _____________________________________________________ Neurologic AB N _____________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ Comments: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ ___________________________________ ______________________________ Physician’s Signature Physician’s Phone 8 Revised August 2015 Name: ____________________________ Date: _________________ Sport: _______________ Flexibility Screening Optional Section: Spine R L _______________________________________________________ Neck R L _______________________________________________________ Ankle R L _______________________________________________________ Feet R L _______________________________________________________ Knee R L _______________________________________________________ Hip R L _______________________________________________________ Back Test: Squat R L _______________________________________________________ Repetitive: Flexion R L _______________________________________________________ Extension R L _______________________________________________________ Prone Trunk Lift R L _______________________________________________________ Participation Recommendations: Pass Fail ______________________________________________________________ __________________________ __________________________ Examiner’s Signature Date Athletic Trainer Clearance Participation Recommendations: Pass Fail ______________________________________________________________ __________________________ Athletic Trainer’s Signature __________________________ Date 9 Revised August 2015