Virginia Sports Form High School

Virginia Sports Form - Part II

Form is required each school year MAY 1 of the current year through JUNE 30 of the succeeding year.
This form is only to be completed electronically if your child has had an annual well check in the preceding 12 months and the child has NOT had any significant changes to his/her medical history

**If the sports form is completed outside of well check there will be a $20 fee payable via the portal
****In order to complete the sports questionnaire, you will need to have your immunization record. Please call the office to obtain this document prior to starting to fill out the form****

PREPARTICIPATION PHYSICAL EVALUATION

HISTORY FORM

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Patient's name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Date of examination

MonthDayYear
Date
Sport(s) blanks . Sex assigned at birth (F,M, or intersex) blank
How do you identify your gender? (F, M, non-binary, or another gender) blanks .
Have you had COVID-19?

YesNo
Have you been immunized for COVID-19?

YesNo
If Yes, have you had:

One shotTwo shotsThree shotsFour shots
Booster date(s) blanks .
List past and current medical conditions blank .
Have you ever had surgery? If yes, list all past surgical procedures blanks . Medicine and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional) blank .
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects) blanks .

Patient Health Questionnaire Version 4 (PHQ-4) - Over the last 2 weeks, how often have you been bothered by any of the following problems? (Check mark response)

	Not at all	Several days	Over half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

General Questions (In the questions below, Explain all "YES" answers within the text box)
1. Do you have any concerns that you would like to discuss with your provider?*
If yes, explain:
2. Has a provider ever denied or restricted your participation in sports for any reason?*
If yes, explain:
3. Do you have any ongoing medical issue or recent illness? If so, please identify:*

NoAsthmaAnemiaDiabetesInfectionsOther

Heart health Questions about you
4. Have you ever passed out or nearly passed out DURING or AFTER exercise?*
If yes, explain:
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*
If yes, explain:
6. Does your heart race, flutter in your chest or skip beats (irregular beats) during exercise?*
If yes, explain:
7. Has a doctor ever told you that you have any heart problems?:*

YesNo
8. Has a doctor every ordered a test for your heart? For example, electrocardiography and echocardiography.*
If yes, explain:
9. Do you get light-headed or feel shorter of breath than your friends during exercise?*
If yes, explain:
10. Have you ever had a seizure?*
If yes, explain:

Heart Health Questions about your Family
11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car crash)?*
If yes, explain:
12. 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)?*
If yes, explain:
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?*
If yes, explain:

Bone and Joint Questions
14. 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?*
If yes, explain:
15. Do you currently have a bone, muscle, ligament, or joint injury that bothers you?*
If yes, explain:

Medical Questions
16. Do you cough, wheeze or have difficulty breathing during or after exercise?*
If yes, explain:
17. Are you missing a kidney, eye, testicle, spleen or other internal organ?*
If yes, explain:
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*
If yes, explain:
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?*
If yes, explain:
20. Have you had a concussion or head injury that caused confusion, a prolonged headache or memory problems? *
If yes, explain:
21. Have you ever had numbness, tingling or weakness in your arms or legs or been unable to move your arms or legs AFTER being hit or falling?*
If yes, explain:
22. Have you ever become ill while exercising in the heat?*
If yes, explain:
23. Do you or does someone in your family have sickle cell trait or disease?*
If yes, explain:
24. Have you had or do you have any problems with your eyes or vision?*
If yes, explain:
25. Do you worry about your weight?*
If yes, explain:
26. Are you trying to or has anyone recommended that you gain or lose weight?*
If yes, explain:
27. Are you on a special diet or do you avoid certain types of foods or food groups?*
If yes, explain:
28. Have you ever had an eating disorder?*
If yes, explain:

Menstrual Questions
29. Have you ever had a menstrual period?
30. How old were you when you had your first menstrual period:
31. When was your most recent menstrual period?
32. How many periods have you had in the past 12 months:
Additional comments:
I hereby state that to the best of my knowledge, my answers to the questions on this form are complete and correct. Athlete's signature:

Clear
Parent or Guardian Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Virginia Sports Form - Part II