UHSAA Pre-Participation Physical Form

Name of Student*

Birth date*

Date

Athlete Address

Age

Gender*

Grade in school

School

School year

Sport(s)

Is the student covered by health/accident insurance?*

YesNo

Name of health insurance provider

If no insurance provider, explain

Providers Name

Name of provider you have your appointment scheduled with

Providers Address

Providers Phone Number

Please enter a valid phone number.

Please list all of the prescription and over-the-counter medicine and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?*

YesNo

What type of allergy do you have?*

MedicinesPollensFoodStinging Insects

Specify Medications*

Specify Pollens*

Specify Foods*

Specify Insects*

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

YesNo

Please explain:

Do you have any ongoing medical conditions? If so please identify below*

Have you ever spent the night in the hospital?*

YesNo

Please explain:

Have you ever had surgery?*

YesNo

Please explain:

Have you ever passed out or nearly passed out DURING or AFTER exercise?*

YesNo

Please explain:

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

YesNo

Please explain:

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

YesNo

Please explain:

Has a doctor ever told you that you have any heart problems? If so check all that Apply:*

Has a doctor ever ordered a test for your heart? (e.g. ECG/EKG,Echocardiogram)?*

YesNo

Please explain:

Do you get light headed or feel more short of breath than expected during exercise?*

YesNo

Please explain:

Have you ever had an unexplained seizure?*

YesNo

Please explain:

Do you get more tired or short of breath more quickly than your friends during exercise?*

YesNo

Please explain:

Has any family member or relative died of a heart problem or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?*

YesNo

Please explain:

Does anyone in your family have hypertrophic cardiomyopathy, Long QT syndrome, Short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?*

YesNo

Please explain:

Does anyone in your family have a heart problem, pacemaker, or implanted Defibrillator?*

YesNo

Please explain:

Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?*

YesNo

Please explain:

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

YesNo

Please explain:

Have you ever had any broken, fractured or dislocated bones?*

YesNo

Please explain:

Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches?*

YesNo

Please explain:

Have you ever had a stress fracture?*

YesNo

Please explain:

Have you ever been told that you have or have you had an x-ray for a neck instability or atlantoaxial instability (down syndrome or dwarfism)?*

YesNo

Please explain:

Do you regularly use a brace, orthotics, or other assistive devices?*

YesNo

Please explain:

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

YesNo

Please explain:

Do any of your joints become painful, swollen, feel warm or look red?*

YesNo

Please explain:

Do you have any history of juvenile arthritis, or connective tissue disease?*

YesNo

Please explain:

Have you had any problems with pain, swelling, fracture, sprain, strain, or dislocation in any joint?*

YesNo

Which joint(s)?*

Head- Explain

Neck- Explain

Back- Explain

Shoulder- Explain

Arm- Explain

Elbow- Explain

Finger- Explain

Wrist- Explain

Hand- Explain

Shin/Calf- Explain

Thigh- Explain

Knee- Explain

Hip- Explain

Ankle- Explain

Foot- Explain

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

YesNo

Please explain:

Have you ever used an inhaler or taken asthma medication?*

YesNo

Please explain:

Is there anyone in your family who has asthma?*

YesNo

Please explain:

Were you born without or are you missing a kidney, an eye, a testicle (males),your spleen, or any other organ?*

YesNo

Please explain:

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

YesNo

Please explain:

Have you had infectious mononucleosis (mono) within the last month?*

YesNo

Please explain:

Do you have any rashes, pressure sores, or other skin problems?*

YesNo

Please explain:

Have you had a herpes or MRSA skin infection?*

YesNo

Please explain:

Do you have a history of seizure disorder?*

YesNo

Please explain:

Have you had any problems with your eyes or vision?*

YesNo

Please explain:

Have you had any eye injuries?*

YesNo

Please explain:

Do you wear glasses or contact lenses?*

YesNo

Please explain:

Do you wear protective eye wear such as goggles, or a face shield?*

YesNo

Please explain:

Do you worry about your weight?*

YesNo

Please explain:

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

YesNo

Please explain:

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

YesNo

Please explain:

Have you ever had an eating disorder?*

YesNo

Please explain:

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

YesNo

Please explain:

Do you get frequent muscle cramps when exercising?*

YesNo

Please explain:

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

YesNo

Please explain:

Do you have headaches with exercise?*

YesNo

Please explain:

Have you ever had a head injury or concussion?*

YesNo

Please explain:

Have you ever had a hit or blow to the head that caused confusion,prolonged headache or memory problems?*

YesNo

Please explain:

Have you ever had numbness , tingling, or weakness in your arms of legs afterbeing hit or falling?*

YesNo

Please explain:

Have you ever been unable to move your arms or legs after being hit or falling?*

YesNo

Please explain:

When was your first menstrual period (age when started)?*

When was your most recent menstrual period?*

How much time do you usually have from the start of one period to the start of another?*

How many periods have you had in the last year?*

What was the longest time between periods in the last year?*

PLEASE NOTE: It is the responsibility of the parent/guardian to notify the school if there are any unique individual problems that are not listed on the Pre-participation Physical Evaluation Form. **This Pre-Participation Evaluation DOES NOT replace the Child Wellness Evaluation by you family medical provider.

Parent or Guardian Statement of Permission, Approval, and Acknowledgement By signing below, I the parent or legal guardian of the above named student do: Hereby consent to the above named student participating in the interscholastic athletic program at the school listed above. This consent includes travel to and from athletic contests and practice sessions. Further consent to treatment deemed necessary by health care providers designated by school authorities for any illness or injury resulting from his/her athletic participation. Recognize that a risk of possible injury is inherent in all sports participation. I further realize that potential injuries may be severe in nature including such conditions as: fractures, brain injuries, paralysis or even death. Acknowledge and give consent that a copy of this form will remain in the student's school. I agree that if my student's health changes and would alter this evaluation, I will notify the school as soon as possible but within no longer than 10 days. Hereby acknowledge having received education including receiving written information regarding the signs, symptoms, and risks of sport related concussion. I also acknowledge that I have read, understand and agree to abide by the UHSAA Concussion Management Policy and/or the policy of the school listed above. http://www.uhsaa.org/SportsMed/ConcussionManagementPlan.po

Parent or Guardian Name*

Parent or Guardian Signature*

Date*

Date

By signing below I acknowledge: This application to compete in interscholastic athletics for the above school is entirely voluntary on my part and is made with the understanding that I have not violated any of the eligibility rules and regulations of the Utah High School Activities Association. My responsibility to report to my coaches and parent(s)/guardian(s) illness or injury I experience. Having received education including receiving written information regarding signs, symptoms, and risks of sport related concussion. I also acknowledge my responsibility to report to my coaches and parent(s)/guardian(s) any signs or symptoms of a concussion.

Signature of Student*

Date*

Date