Athletic Profile Freeport High School Name Date Sport Address

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Athletic Profile Freeport High School
Name
Date
Sport
Address
Birthdate
Family Physician
Height
Weight
Blood Pressure
Heart Rate
Vertical Jump
40-yard Dash
Notes:
Telephone
Athletic Pre-Participation Physical Evaluation Form
Part A: Health History Questionnaire
(to be completed by parent and student)
Directions: Please answer the following questions about the student’s medical history.
Explain all “yes” responses. Please respond to all questions. (Circle letter and
responses)
1. Have you had or do you currently have:
A. a sports physical within the past 365 days?
B. an injury or illness since your last exam?
C. a chronic or ongoing illness (such as diabetes or asthma)?
D. any prescribed or over-the counter medications that you take
on a regular basis? (list below)
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
E. surgery, hospitalization, or any emergency room visit(s)?
Y / N / Don’t Know
F. any allergies to medications?
Y / N / Don’t Know
G. any allergies to bee sting, pollen, latex, or foods?
Y / N / Don’t Know
1. Any type of reaction: rash hives other skin conditions Y / N / Don’t Know
(circle all that apply)
2. Take any medication / Epipen taken for allergy symptoms? Y / N / Don’t Know
H. Any anemia or blood disorders?
Y / N / Don’t Know
2. Have you had or do you currently have any of the following head related conditions
since your last physical?
A. Concussions requiring a physician’s evaluation?
Y / N / Don’t Know
How often and when?
B. Memory loss or been knocked-out?
C. A seizure?
D. Frequent or severe headaches?
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
3. Have you had or do you currently have any of the following heart related conditions
since your last physical?
A. Chest pains?
Y / N / Don’t Know
B. Heart murmur?
Y / N / Don’t Know
C. High blood pressure or elevated cholesterol levels?
Y / N / Don’t Know
D. Restricted from sports because of a heart problem?
Y / N / Don’t Know
E. Any family members or relatives:
1. die of a heart problem before age 35?
Y / N / Don’t Know
2. die of a heart problem before age 50?
Y / N / Don’t Know
3. die with no known reason?
Y / N / Don’t Know
4. die while exercising? During or after? (circle one)
Y / N / Don’t Know
5. with Marfan’s Syndrome?
Y / N / Don’t Know
4. Have you had or do you have any of the following eye, ear, nose, mouth, or throat
conditions since your last physical?
A. Vision problems?
Y / N / Don’t Know
Wear contacts, eyeglasses, or protective eye wear? (circle one)
B. Hearing loss or problems?
Y / N / Don’t Know
Wearing hearing aids or implants?
Y / N / Don’t Know
C. Nasal fractures or frequent nose bleeds?
Y / N / Don’t Know
D. Wear braces, retainers, or protective mouth gear?
Y / N / Don’t Know
E. Frequent strep or any other conditions of the throat?
Y / N / Don’t Know
5. Have you had or do you have any of the following neuromuscular orthopedic
conditions since your last physical?
A. A burner, stinger, or pinched nerve?
Y / N / Don’t Know
B. A sprain or strain?
Y / N / Don’t Know
D. Pain or swelling in any muscle, tendon, bone, or joint?
Y / N / Don’t Know
E. A dislocated joint?
Y / N / Don’t Know
F. Upper or lower back pain?
Y / N / Don’t Know
G. Do you wear any protective braces from a prior injury?
Y / N / Don’t Know
6. Have you had or do you have any of the following general or exercise related
conditions since your last physical?
A. Difficulty breathing? During exercise? (circle one)
Y / N / Don’t Know
1. After running one mile
Y / N / Don’t Know
2. Coughing, wheezing, or shortness of breath in weather
changes?
Y / N / Don’t Know
3. Exercise induced asthma
Y / N / Don’t Know
Controlled with medications?
Y / N / Don’t Know
Experience dizziness, passing-out, or fainting
Y / N / Don’t Know
B. Viral infections (e.g. Hepatitis or mono)
C. Become tired more quickly than your friends
D. Any of the following skin conditions:
1. Acne, contact dermatitis, ringworm, warts, herpes?
2. Sun sensitivity?
E. Weight gain / loss greater than 10 pounds?
F. Ever had feelings of depression?
G. Heat-related problems (dehydration, dizziness, fatigue, or
headache)?
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
Y / N / Don’t Know
1. Heat exhaustion (cool, clammy, or damp skin)?
2. Heat stroke (hot, red, dry skin)?
Y / N / Don’t Know
Y / N / Don’t Know
7. Check one:
This is the FIRST TIME this health questionnaire has been completed for
the upcoming school year.
There is NO CHANGE to the previous health questionnaire filled out this
school year.
There are CHANGES to the previous health questionnaire filled out this
school year.
8. FEMALES ONLY:
Age of onset of menstruation:
Date of last menstruation:
Most number of days between menstruation cycle(s):
Explain all Yes answers here (include relevant dates)
I understand that although a physical exam is still required for the upcoming sports
season, it is my responsibility to keep my medical history questionnaire updated through
the school of participation.
We certify that the information provided herein is accurate to the best of our knowledge
as of the date of these signatures.
Parent / Guardian Signature:
Date:
Student Signature:
Date:
Part B: Musculoskeletal Exam
(to be completed by examining therapist or trainer)
ROM STRENGTH
Normal / Abnormal
(circle one)
ROM STRENGTH
Normal / Abnormal
(circle one)
SPINE - CERVICAL
LOWER EXTREMITY
N
A
Flexion / Extension
N
A
Hip
N
A
Rotation right / left
N
A
Hip Flexors / Gluteals
N
A
Lateral flexion right / left
N
A
Abduction / Adduction – Groin / TT
N
A
SPINE – THORACIC
N
A
Interior / exterior rotation
SPINE – LUMBAR
N
A
Knee
N
A
Flexion / Extension
N
A
Patellar Tendon
N
A
Rotation right / left
N
A
Tibial Tuberosity
N
A
Lateral flexion right / left
N
A
MCL / LCL
N
A
Abdominal / Obliques (STR)
N
A
ACL / PCL
UPPER EXTREMITY
N
A
Cartilage Testing
N
A
Shoulder
N
A
Quads / Hamstrings
N
A
Forward flexion / extension
N
A
Gast / Soleus Complex
N
A
Abduction / adduction
N
A
Patella
N
A
Internal / external rotation
N
A
Crepitus
N
A
Horizontal abduction / adduction
N
A
Tracking
N
A
A C Joint / Clavicle
N
A
Ankle
N
A
Stability Testing
N
A
Plantar / Dorsiflexion
N
A
Biceps flexion / extension
N
A
Inversion / Eversion
N
A
Elbow
N
A
Subtalar Joint
N
A
Supination / pronation
N
A
Ligament Testing
N
A
Wrist / hand
N
A
Feet / Toes
GENERAL FLEXIBILITY
N
A
Hamstrings
N
A
Quadriceps
N
A
Lumbar Spine
N
A
Achilles
Part C: Special Testing for Above Body Parts
(to be completed by examining therapist or trainer)
Cervical Spine
Vertebral Artery Test
Foraminal Compression Test (Spurling)
Foraminal Distraction Test
Valsalva’s Maneuver
Swallowing Test
Tinel’s Sign
Notes
N/A
N/A
N/A
N/A
N/A
N/A
Thoracic Spine
Kernig / Brudzinski Signs
Lateral Rib Compression Test
Anterior / Posterior Rib Compression Test
Inspiration / Expiration Breathing Test
Lumbar Spine
Valsalva’s Maneuver
Stoop Test
90-90 Straight Leg Raise Test
Bowstring Test (Cram Test)
Unilateral Straight Leg Raise Test
Bilateral Straight Leg Raise Test
Well Straight Leg Raise Test
Slump Test
Thomas Test
Spring Test
Notes
N/A
N/A
N/A
N/A
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Shoulder
Empty Can (Supraspinatus) Test
Yergason Test
Speed’s Test
Drop Arm Test
Apley’s Scratch Test
Cross-Over Impingement Test
Sternoclavicular (SC) Joint Stress Test
Acromioclavicular (AC) Joint Distraction Test
Apprehension Test (Anterior)
Apprehension Test (Posterior)
Brachial Plexus Stretch Test
Shoulder Abduction Test
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Elbow
Resistive Tennis Elbow Test (Cozen’s Test)
Resistive Tennis Elbow Test
Passive Tennis Elbow Test
Golfer’s Elbow Test
Hyperextension Test
Elbow Flexion Test
Varus Stress Test
Valgus Stress Test
Tinel’s Sign
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Wrist and Hand
Compression Test
Long Finger Flexion Test
Finkelstein Test
Phalen Test
Tinel’s Sign
Bunnel Littler Test
Murphy’s Sign
Valgus Stress Test
Varus Stress Test
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Knee
Patellar Apprehension Test
Quadriceps or Q-Angle Test
Medial-Lateral Grind Test
Bounce Home Test
Patellar Grind Test (Clarke’s Sign)
Hughston’s Plica Test
Posterior Sag Test (Gravity Drawer Test)
Reverse Pivot Shift (Jakob Test)
Anterior Lachman’s Test
Anterior Drawer Test
Slocum Test with Internal Tibial Rotation
Slocum Test with External Tibial Rotation
Pivot Shift Test
Posterior Drawer Test
Posterior Lachman’s Test 27
External Rotation Recurvatum Test
Valgus Stress Test
Varus Stress Test
McMurray Test
Apley Compression Test
Rectus Femoris Contracture Test
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Ankle and Foot
Anterior Drawer Test
Talar Tilt Test (Inversion)
Talar Tilt Test (Eversion)
Thompson Test
Tap or Percussion Test
Interdigital Neuroma Test
Compression Test
Long Bone Compression Test
Swing Test
Tinel’s Sign
Notes
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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