PHYSICAL EXAMINATION FORM - VALID FOR 2 YEARS

Pre-Participation Physical Evaluation

Physical Examination Form-Valid for 2 Years
Medical History
Name*
First and Last Name
Date of Birth*

MonthDayYear
Sex assigned at birth?*
How do you identify your gender?*
List past and current medical conditions.*
If none, put "none"
Have you ever had surgery?*

YesNo
Please list all past surgical procedures:
Medicines and supplements: List all current prescriptions, over-the-counter medicines and supplements (herbal and nutritional):*
If none, put "none"
Do you have any allergies?*

YesNo
Please list all of your allergies (i.e., medicines, pollens, food, stinging insects):
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious or on edge:*

Not at allSeveral daysOver half the daysNearly every day
Not being able to stop or control worrying:*

Not at allSeveral daysOver half the daysNearly every day
Little interest or pleasure in doing things:*

Not at allSeveral daysOver half the daysNearly every day
Feeling down, depressed or hopeless:*

Not at allSeveral daysOver half the daysNearly every day
Explain "Yes" answers at the end of this form.
Do you have any concerns that you would like to discuss with your provider?*

YesNo
Has a provider ever denied or restricted your participation in sports for any reason?*

YesNo
Do you have any ongoing medical issues or recent illness?*

YesNo
Have you ever passed out or nearly passed out during or after exercise?*

YesNo
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*

YesNo
Does your heart ever race or skip beats (irregular beats) during exercise?*

YesNo
Has a doctor ever told you that you have any heart problems?*

YesNo
Has a doctor ever ordered a test for your heart? (For example, electrocardiography (ECG) or echocardiography?*

YesNo
Do you get light-headed or feel shorter of breath than your friends during exercise?*

YesNo
Have you ever had a seizure?*

YesNo
Has any family member or relative died of heart problems or had an unexpected sudden death before age 35 (including drowning or unexplained car crash)?*

YesNo
Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia (CPVT)?*

YesNo
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?*

YesNo
Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?*

YesNo
Do you have a bone, muscle, ligament, or joint injury that bothers you?*

YesNo
Do you cough, wheeze, or have difficulty breathing during or after exercise?*

YesNo
Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?*

YesNo
Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*

YesNo
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?*

YesNo
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?*

YesNo
Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?*

YesNo
Have you ever become ill while exercising in the heat?*

YesNo
Do you, or does someone in your family, have sickle cell trait or disease?*

YesNo
Have you ever had, or do you have, any problems with your eyes or vision?*

YesNo
Do you worry about your weight?*

YesNo
Are you trying to, or has anyone recommended, that you gain or lose weight?*

YesNo
Are you on a special diet or do you avoid certain types of foods or food groups?*

YesNo
Have you ever had an eating disorder?*

YesNo
Have you ever had a menstrual period?*

YesNoNot Applicable
How old were you when you had your first menstrual period?
When was your most recent menstrual period?
How many periods have you had in the past 12 months?
Please explain all "Yes" answers here:
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signature of Athlete*

Clear
Signature of Parent(s) or Guardian*

Clear
Date*

MonthDayYear
Today's Date
Should be Empty:

Pre-Participation Physical Evaluation

Medical History

Patient Health Questionnaire Version 4 (PHQ-4)