Pre Participation Physical Evaluation
KANSAS STATE HIGH SCHOOL ACTIVITIES ASSOCIATION
PO Box 495, 601 SW Commerce Place; Topeka, KS 66601-0495; (785) 273-5329
PPE
HISTORY
PRE-PARTICIPATION PHYSICAL EVALUATION
Name
Sex
Age
Date of birth
TO BE COMPLETED ANNUALLY BY EVERY PARTICIPANT AND PARENT OR GUARDIAN
Grade
School
Sport(s)
Address
Phone ( )
Personal physician
Parent Email
In case of emergency, contact:
Name
Relationship
Phone (H)
(W)
PPE shall not be taken earlier than May 1 preceding the school year for which it is applicable.
STUDENT/PARENT/GUARDIAN - answer questions below PRIOR TO EXAMINATION by physician.
Explain “YES” answers in space below. Circle the number of the questions you do not know.
YES NO
YES NO
1.
Have you had a medical illness or injury since your last
10.
Do you use any special protective or corrective equipment or
check up or sports physical?
devices that aren’t usually used for your sport or position (for
Do you have an ongoing or chronic illness?
example, knee brace, special neck roll, foot orthotics, retainer
2.
Have you ever been hospitalized overnight?
on your teeth, hearing aid)?
Have you ever had surgery?
11.
Have you had any problems with your eyes or vision?
3.
Are you currently taking any prescription or non-prescription
Do you wear glasses, contacts, or protective eyewear?
(over-the-counter) medications or pills or using an
12.
Have you ever had a sprain, strain, fracture or dislocation
inhaler?
of a muscle, tendon, bone or joint?
Have you ever taken any supplements or vitamins to help
If yes, check appropriate box and explain below.
you gain or lose weight or improve your performance?
Head
Elbow
Hip
4.
Do you have any allergies (for example, to pollen, medicine,
Neck
Forearm
Thigh
food, or stinging insects)? Have you ever had a rash or hives
Back
Wrist
Knee
develop during or after exercise?
Chest
Hand
Shin/calf
5.
Have you ever passed out during or after exercise?
Shoulder
Finger
Ankle
Have you ever been dizzy during or after exercise?
Upper arm
Foot
Have you ever had chest pain during or after exercise?
13.
Do you want to weigh more or less than you do now?
Do you get tired more quickly than your friends do during
exercise?
Do you lose weight regularly to meet weight requirements
for your sport?
Have you ever had racing of your heart or skipped heartbeats?
14.
Has a doctor told you or a family member that you are at
Have you had high blood pressure or high cholesterol?
risk for blood disorders? Ex: Sickle Cell, etc…
Have you ever been told you have a heart murmur?
15.
Were you born without or are you missing a kidney, testicle
Has any family member or relative died of heart problems
or any other organs?
or of sudden death before age 50?
16
Do you feel that you have fatigue or increased shortness of
Have you had a severe viral infection (for example, myocarditis
breath with activity?
or mononucleosis) within the last month?
17.
Do you have any concerns that you would like to discuss
Has a physician ever denied or restricted your participation
with the doctor?
in sports for any heart problems?
6.
Do you have any current skin problems (for example itching,
FEMALES ONLY
rashes, acne, warts, fungus, or blisters)?
18.
Have you begun menstruation?
7.
Have you ever had a head injury or concussion?
If yes, are you ever experiencing any problem
When? ________________________ How many? ________
(i.e., irregularity, pain, etc.)?
Have you ever been knocked out, become unconscious, or
lost your memory?
IDENTIFY “YES” ANSWERS (by number)
Have you ever had a seizure?
Have you ever had numbness or tingling in your arms, hands,
legs, or feet?
Have you ever had a stinger, burner, or pinched nerve?
8.
Have you ever become ill from exercising in the heat?
9.
Do you cough, wheeze, or have trouble breathing during or
after activity?
Do you have asthma?
Do you use an inhaler before excercise?
Do you have seasonal allergies requiring medical treatment?
Rev. 3/09
PHYSICAL EXAMINATION
PRE-PARTICIPATION PHYSICAL EVALUATION
Name
Date of Birth
Height
Weight
Pulse
Blood Pressure
/
Vision
R 20/ L 20/
Corrected: Y N
Pupils: Equal
Unequal
Date of recent immunizations: Td
Tdap
Hep B
Varicella
HPV
Meningococcal
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Lymph Nodes
Heart
Pulses
Lungs
Abdomen
Genitalia/Hernia
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand
Hip/Thigh
Knee
Leg/Ankle
Foot
*Station-based examination only
CLEARANCE
Cleared for all activities
Not cleared for: _________________________________________________________________________________________________________________
Reason:
Recommendations:
I HEREBY CERTIFY THAT I AM qUALIFIED BY TRAINING AND EXPERIENCE TO PROPERLY PERFORM THE EXAMINATION
AND MAKE THE EVALUATION REFLECTED ON THIS FORM
Name of physician (print/type)
Date
Address
Phone ( )
Signature of physician
, MD, DO, DC or RPA
(please circle)
ATTENTION PARENTS AND STUDENTS
KSHSAA ELIGIBILITY CHECK LIST
PPE shall not be taken earlier than May 1 preceding the school year for which it is applicable.
NOTE: Transfer Rule 18 states in part, a student is eligible transfer-wise if:
BEGINNING SEVENTH GRADER—A seventh grader, at the beginning of his or her seventh grade year,
is eligible under the Transfer Rule at any school he or she may choose to attend. In addition, age and
academic eligibility requirements must also be met.
BEGINNING NINTH GRADERS IN A THREE-YEAR JUNIOR HIGH SCHOOL—So that ninth graders
of a three-year junior high are treated equally to ninth graders of a four-year senior high school, a student
who has successfully completed the eighth grade of a two-year junior high/middle school, may transfer
to the ninth grade of a three-year junior high school at the beginning of the school year and be eligible
immediately under the Transfer Rule. Such a ninth grader must then as a tenth grader, attend the feeder
senior high school of their school system. Should they attend a different school as a tenth grader, they
would be ineligible for eighteen weeks.
ENTERING HIGH SCHOOL FOR THE FIRST TIME—A senior high school student is eligible under the
Transfer Rule at any senior high school he or she may choose to attend when senior high is entered for
the first time at the beginning of the school year. In addition, age and academic eligibility requirements
must also be met.
For Middle/Junior High and Senior High School Students to Retain Eligibility
Schools may have stricter rules than those pertaining to the questions above or listed below. Contact the principal
or coach on any matter of eligibility. A student to be eligible to participate in interscholastic activities must be certified
by the school principal as meeting all eligibility standards.
All KSHSAA rules and regulations are published in the official KSHSAA Handbook which is distributed annually and
is available at your school principal’s office.
Below Are Brief Summaries Of Selected Rules. Please See Your Principal For Complete Information.
Rule 7 Physical Evaluation - Parental Consent—Students shall have passed the attached evaluation given
by a physician and have the written consent of their parents or legal guardian.
Rule 14 Bona Fide Student—Eligible students shall be a bona fide undergraduate member of his/her school in
good standing.
Rule 15 Enrollment/Attendance—Students must be regularly enrolled and in attendance not later than Monday
of the fourth week of the semester in which they participate.
Rule 16 Semester Requirements—A student shall not have more than two semesters of possible eligibility in
grade seven and two semesters in grade eight. A student shall not have more than eight semesters of
possible eligibility in grades nine through twelve, regardless of whether the ninth grade is included in
junior high or in a senior high school.
NOTE: If a student does not participate or is ineligible due to transfer, scholarship, etc., the semester(s)
during that period shall be counted toward the total number of semesters possible.
Rule 17 Age Requirements—Students are eligible if they are not 19 years of age (16, 15 or 14 for junior high or
middle school student) on or before September 1 of the school year in which they compete.
Rule 19 Undue Influence—The use of undue influence by any person to secure or retain a student shall cause
ineligibility. If tuition is charged or reduced, it shall meet the requirements of the KSHSAA.
Rules 20/21 Amateur and Awards Rules—Students are eligible if they have not competed under a false name
or for money or merchandise of intrinsic value, and have observed all other provisions of the Amateur and
Awards Rules.
Rule 22 Outside Competition—Students may not engage in outside competition in the same sport during a
season in which they are
representing their school.
NOTE: Consult the coach or principal before participating individually or on a team in any game, training
session, contest, or tryout conducted by an outside organization.
Rule 25 Anti-Fraternity—Students are eligible if they are not members of any fraternity or other organization
prohibited by law or by the rules of the KSHSAA.
Rule 26 Anti-Tryout and Private Instruction—Students are eligible if they have not participated in training
sessions or tryouts held by colleges or other outside agencies or organizations in the same sport while a
member of a school athletic team.
Rule 30 Seasons of Sport—Students are not eligible for more than four seasons in one sport in a four-year high
school, three seasons in a three-year high school or two seasons in a two-year high school.
Student’s Name _______________________________________________
(PLEASE PRINT CLEARLY)
To be eligible for participation in interscholastic athletics/spirit groups, a student must have on file with the superintendent or principal, a signed
statement by a practicing physician or registered physicians assistant certifying the student has passed an adequate physical examination and is
physically fit to participate. (See KSHSAA Handbook, Rule 7.) A complete history and physical examination must be performed upon a student’s
initial entrance into KSHSAA interscholastic athletics/cheerleading.
The annual history and the physical examination shall not be taken earlier than May 1 preceding the school year for which it is
applicable. The KSHSAA recommends completion of this evaluation by athletes/cheerleaders at least one month prior to the first practice to allow
time for correction of deficiencies and implementation of conditioning recommendations.
Parent or Guardian Consent
I do not know of any existing physical or any additional health reasons that would preclude participation in
activities. I certify that the answers to the questions in the HISTORY part of the Preparticipation Physical
Examination (PPE), are true and accurate. I approve participation in activities. I hereby authorize release to the
KSHSAA, the school nurse, trainer, coach and medical provider of information contained in this document. Upon
written request, I may receive a copy of this document for my own personal health care records.
I acknowledge that there are risks of participating, including the possibility of catastrophic injury.
I hereby give my consent for the above student to compete in KSHSAA approved activities, and to accompany
school representatives on school trips and receive emergency medical treatment when necessary. It is understood
that neither the KSHSAA nor the school assumes any responsibility in case of accident. The undersigned agrees
to be responsible for the safe return of all equipment issued by the school to the student.
The above named student and I have read the
KSHSAA Eligibility Check List
and how to retain eligibility information listed in this form.
For Middle/Junior High and Senior High School Students to Determine Eligibility When Enrolling
If a negative response is given to any of the following questions, this enrollee should contact his/her administrator in charge of evaluating
eligibility. This should be done before the student is allowed to attend his/her first class and prior to the first activity practice. If questions
still exist, the school administrator should telephone the KSHSAA for a final determination of eligibility. (Schools shall process a Certificate
of Transfer Form T-E on all transfer students.)
YES NO
1.
Are you a bona fide student in good standing in school? (If there is a question, your principal will make that determination.)
2.
Did you pass at least five new subjects (those not previously passed) last semester? (The KSHSAA has a minimum
regulation which requires you to pass at least five subjects of unit weight in your last semester of attendance.)
3.
Are you planning to enroll in at least five new subjects (those not previously passed) of unit weight this coming semester?
(The KSHSAA has a minimum regulation which requires you to enroll and be in attendance in at least five subjects of unit weight.)
4.
Did you attend this school or a feeder school in your district last semester? (If the answer is “no” to this question, please answer
Sections a and b.)
a. Do you reside with your parents?
b. If you reside with your parents, have they made a permanent and bona fide move into your school’s attendance center?
The student/parent authorizes the school to release to the KSHSAA student records and other pertinent documents and infor-
mation for the purpose of determining student eligibility. The student/parent also authorizes the school and the KSHSAA to
publish the name and picture of student as a result of participating in or attending extra-curricular activities, school events
and KSHSAA activities or events.
Parent or Guardian’s Signature
Date
Student’s Signature
Date
Birth Date
Grade
