Preparticipation Physical Evaluation (page 1 Of 2)
EL2
Florida High School Athletic Association
Revised 06/09
Preparticipation Physical Evaluation (Page 1 of 2)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
Part 1. Student Information (to be completed by student or parent)
Student’s Name: ________________________________________________________________________ Sex: _____ Age: _____ Date of Birth: _____/ _____/ _____
School: ____________________________________________________ Grade in School: _____ Sport(s): ________________________________________________
Home Address: _______________________________________________________________________________________ Home Phone: ( _____) _______________
Name of Parent/Guardian: _______________________________________________________________ E-mail: ___________________________________________
Person to Contact in Case of Emergency: _____________________________________________________________________________________________________
Relationship to Student: _______________________ Home Phone: ( _____) ______________ Work Phone: ( _____) _____________ Cell Phone: ( _____) _____________
Personal/Family Physician: ___________________________________________City/State: ___________________________ Office Phone: ( _____) _____________
Part 2. Medical History (to be completed by student or parent). Explain “yes” answers below. Circle questions you don’t know answers to.
Yes No
Yes No
1. Have you had a medical illness or injury since your last ____ ____
26. Have you ever become ill from exercising in the heat?
____ ____
check up or sports physical?
27. Do you cough, wheeze or have trouble breathing during or after
____ ____
2. Do you have an ongoing chronic illness?
____ ____
activity?
3. Have you ever been hospitalized overnight?
____ ____
28. Do you have asthma?
____ ____
4. Have you ever had surgery?
____ ____
29. Do you have seasonal allergies that require medical treatment?
____ ____
5. Are you currently taking any prescription or non-
____ ____
30. Do you use any special protective or corrective equipment or
____ ____
prescription (over-the-counter) medications or pills or
devices that aren’t usually used for your sport or position (for
using an inhaler?
example, knee brace, special neck roll, foot orthotics, retainer on
6. Have you ever taken any supplements or vitamins to
____ ____
your teeth or hearing aid)?
help you gain or lose weight or improve your
31. Have you had any problems with your eyes or vision?
____ ____
performance?
32. Do you wear glasses, contacts or protective eyewear?
____ ____
7. Do you have any allergies (for example, to pollen,
____ ____
33. Have you ever had a sprain, strain or swelling after injury?
____ ____
medicine, food or stinging insects)?
34. Have you broken or fractured any bones or dislocated any joints?
____ ____
8. Have you ever had a rash or hives develop during or
____ ____
35. Have you had any other problems with pain or swelling in muscles, ____ ____
after exercise?
tendons, bones or joints?
9. Have you ever passed out during or after exercise?
____ ____
If yes, check appropriate blank and explain below:
10. Have you ever been dizzy during or after exercise?
____ ____
___ Head
___ Elbow
___ Hip
11. Have you ever had chest pain during or after exercise? ____ ____
___ Neck
___ Forearm
___ Thigh
12. Do you get tired more quickly than your friends do
____ ____
___ Back
___ Wrist
___ Knee
during exercise?
___ Chest
___ Hand
___ Shin/Calf
13. Have you ever had racing of your heart or skipped
____ ____
___ Shoulder
___ Finger
___ Ankle
heartbeats?
___ Upper Arm
___ Foot
14. Have you had high blood pressure or high cholesterol? ____ ____
36. Do you want to weigh more or less than you do now?
____ ____
15. Have you ever been told you have a heart murmur?
____ ____
37. Do you lose weight regularly to meet weight requirements for your ____ ____
16. Has any family member or relative died of heart
____ ____
sport?
problems or sudden death before age 50?
38. Do you feel stressed out?
____ ____
17. Have you had a severe viral infection (for example,
____ ____
39. Record the dates of your most recent immunizations (shots) for:
myocarditis or mononucleosis) within the last month?
Tetanus: _______________ Measles: _______________
18. Has a physician ever denied or restricted your
____ ____
Hepatitus B:
participation in sports for any heart problems?
____________ Chickenpox: ____________
19. Do you have any current skin problems (for example,
____ ____
itching, rashes, acne, warts, fungus or blisters)?
FEMALES ONLY (optional)
20. Have you ever had a head injury or concussion?
____ ____
40. When was your first menstrual period? _______________________
21. Have you ever been knocked out, become unconscious ____ ____
41. When was your most recent menstrual period? _________________
or lost your memory?
42. How much time do you usually have from the start of one period to
22. Have you ever had a seizure?
____ ____
the start of another? _______________________________________
23. Do you have frequent or severe headaches?
____ ____
43. How many periods have you had in the last year? _______________
24. Have you ever had numbness or tingling in your arms, ____ ____
44. What was the longest time between periods in the last year? ________
hands, legs or feet?
25. Have you ever had a stinger, burner or pinched nerve?
____ ____
Explain “Yes” answers here: _______________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
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 medical evaluation required by s.1006.20, Florida
Statutes, 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 (EKG), echocardiogram (ECG) and/or cardio stress test.
Signature of Student: _____________________________________ Date: ____/ ____/ ____ Signature of Parent/Guardian: __________________________________ Date: ____/ ____/ ____
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EL2
Florida High School Athletic Association
Revised 06/09
Preparticipation Physical Evaluation (Page 2 of 2)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physi-
cian, licensed physician assistant or certified advanced registered nurse practitioner).
Student’s Name: _____________________________________________________________________________________________ Date of Birth: _____/_____/_____
Height: _____________ Weight: _____________ % Body Fat (optional): ____________ Pulse: _________ Blood Pressure: ____ / ____ ( ____/____ , ____ /____ )
Temperature: _____________ Hearing: right: P ______ F _____ left: P _____ F _____
Visual Acuity: Right 20/_______ Left 20/_______ Corrected: Yes No Pupils: Equal _________ Unequal _________
FINDINGS
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
1. Appearance
________
________________________________________________________________________
____________
2. Eyes/Ears/Nose/Throat
________
________________________________________________________________________
____________
3. Lymph Nodes
________
________________________________________________________________________
____________
4. Heart
________
________________________________________________________________________
____________
5. Pulses
________
________________________________________________________________________
____________
6. Lungs
________
________________________________________________________________________
____________
7. Abdomen
________
________________________________________________________________________
____________
8. Genitalia (males only)
________
________________________________________________________________________
____________
9. Skin
________
________________________________________________________________________
____________
MUSCULOSKELETAL
10. Neck
________
________________________________________________________________________
____________
11. Back
________
________________________________________________________________________
____________
12. Shoulder/Arm
________
________________________________________________________________________
____________
13. Elbow/Forearm
________
________________________________________________________________________
____________
14. Wrist/Hand
________
________________________________________________________________________
____________
15. Hip/Thigh
________
________________________________________________________________________
____________
16. Knee
________
________________________________________________________________________
____________
17. Leg/Ankle
________
________________________________________________________________________
____________
18. Foot
________
________________________________________________________________________
____________
* – station-based examination only
ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________
______________________________________________________________________________________________________________________________________
____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________
____ Referred to ______________________________________________________________________________ For: ______________________________________
______________________________________________________________________________________________________________________________________
Recommendations: _______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Name of Physician/Physician Assistant/Nurse Practitioner (print): ___________________________________________________________ Date: ____/____/_______
Address: _______________________________________________________________________________________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner: ____________________________________________________________________________________
ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)
I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Not cleared for: __________________________________________________________________________ Reason: ___________________________________
____ Cleared after completing evaluation/rehabilitation for: ______________________________________________________________________________________
Recommendations: _______________________________________________________________________________________________________________________
Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______
Address: _______________________________________________________________________________________________________________________________
Signature of Physician: ___________________________________________________________________________________________________________________
Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopae-
dic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.
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