ePreparticipation Physical Evaluation EL2 for pickup

This form is 100% HIPAA Compliant and has been optimized to make it faster and easier for you to complete.
WARNING:

This form should only be used if the student had a physical examination in the last 12 months. If you are unsure, please call the office or visit our Patient Portal and look for the appointment history.
EL2

Revised 3/23
PREPARTICIPATION PHYSICAL EVALUATION (Page 1 of 4)

This medical history form should be retained by the healthcare provider and/or parent.

This form is valid for 365 calendar days from the date signed below.
MEDICAL HISTORY FORM
Student Information (to be completed by student and parent)
Student's Full Name*
Date of Birth*

MonthDayYear
month/Day/year?
Sex Assigned at Birth
Person to Contact in Case of Emergency
Age
School
Grade in School
Sport(s)
all the sports the student would like to be in
Name of Parent/Guardian:*
Parent's / Guardian Email*
example@example.com
Relationship to Student*
Home Address*
City/State
Work Phone

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Other Phone:

Area CodePhone Number
Family Healthcare Provider
Emergency Contact Cell Phone

Area CodePhone Number
Office Phone Number
City/State

Other Phone Number

Area CodePhone Number
Do you have any past and current medical conditions:*
List past and current medical conditions:
Have you ever had surgery? *
If yes, please list all surgical procedures and dates
Do you take an Medicines or supplements*
Please list all current prescription medications, over the counter medicines, and supplements (herbal and nutritional)
Do you have any allergies?*
If yes, please list all of your allergies (i.e., medicines, pollens, food, insects):

GENERAL QUESTIONS (for the student) Explain "Yes" answers at the end of this form. *

	Yes	No	I don't know
1. Do you have any concerns that you would like to discuss with your provider?
2. Has a provider ever denied or restricted your participation in sports for any reason?
3. Do you have any ongoing medical issues or recent illnesses?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY (the student's family)*

	Yes	No	I don't know
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)
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 catecholaminerigc polymorphic ventricular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

PREPARTICIPATION PHYSICAL EVALUATION (Page 2 of 4)

This medical history form should be retained by the healthcare provider and/or parent. This form is valid for 365 calendar days from the date signed below.
Student's Full Name:
Date of Birth

MonthDayYear
Date
School

BONE AND JOINT QUESTIONS (the student)*

	Yes	No	I don't know
14. Have you ever had a stress fracture?
15. Did you ever injure a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?
16. Do you have a bone, muscle, ligament, or joint injury that currently bothers you?

PREPARTICIPATION PHYSICAL EVALUATION (Page 3 of 4) This medical history form should be retained by the healthcare provider and/or parent. This form is valid for 365 calendar days from the date signed below.
EL2
Student's Full Name
Date of Birth

MonthDayYear
Date
School
Address
Office Phone Number
E mail
example@example.com
Student's Full Name
Date of Birth

MonthDayYear
month/Day/year?
Sex Assigned at Birth
School
City/State
Home Phone Number

Area CodePhone Number
Name of Parent/Guardian
Grade in School
Sport's
Home Address:
Email
example@example.com
Relationship to Student
Emergency Contract Cell Phone Number

Area CodePhone Number
Work Phone
Please enter a valid phone number.
Work Phone Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Office Phone Number
Person to Contact in Case of Emergency
Family Healthcare Provider
City/State
Office Phone Number
Address
Student's Full Name
Sex Assigned at Birth
Age
Age
Date of Birth

MonthDayYear
Date
School
Grade in School
Sport(s)
Home Address
City/ State
Name of Parent/Guardian
Email
example@example.com
Person to Contact in Case of Emergency
Relationship to Student
Emergency Contract Cell Phone Number 100

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Other Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Family Healthcare Provider
City/State
Office Phone Number
Address
Office Phone Number1
Please enter a valid phone number.
VERY IMPORTANT: Student's and Parent's Genuine signatures are required to make this form valid. Please Preview your answers before clicking "Submit".
VERY IMPORTANT:

Step 1:

Please Preview your answers to make sure everything is correct.

Step 2:

Print the form and sign with a blue pen (digital signatures are not accepted)

Step 3:

Mail or have the form delivered to our office.

Step 4:

Your provider should have it ready in 3 business days.

Note: This form is free of charge for existing patients. If needed sooner, the rush fee is $25
The front office will have this form ready for you, If no concerns are observed by the provider.
Remember: Print, Sign, and deliver to our office.
Should be Empty:

	Yes	No	I don't know
4. Have you ever passed out or nearly passed out during or after exercise?
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any heart problems?
8. Has a doctor ever requested a test for your heart? for example: electrocardiography (ECG) or echocardiography (ECHO)
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
10. Have you ever had a seizure?

	Yes	No	I don't know
17. Do you cough, wheeze, or have difficulty breathing during or after exercise or has a provider ever diagnosed you with asthma?
18. Are you missing a kidney, an eye, a testicle, your spleen, or any other organ?
19. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
20. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant staphylococcus aureus (MRSA)?
21. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
22. 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?
23. Have you ever become ill while exercising in the heat?
24. Do you or does someone in your family have sickle cell trait or disease?
25. Have you ever had or do you have any problems with your eyes or vision?
26. Do you worry about your weight?
27. Are you trying to or has anyone recommended that you gain or lose weight?
28. Are you on a special diet or do you avoid certain types of foods or food groups?
29. Have you ever had an eating disorder?

This form is 100% HIPAA Compliant and has been optimized to make it faster and easier for you to complete.

EL2

MEDICAL HISTORY FORM

EL2

VERY IMPORTANT: Student's and Parent's Genuine signatures are required to make this form valid. Please Preview your answers before clicking "Submit".

The front office will have this form ready for you, If no concerns are observed by the provider.