Sports Physical Consent Form English

CONSENT FOR ATHLETIC PARTICIPATION & MEDICAL CARE
*Entire Page Completed By Patient/Parent
Form Status
Location*
My child attends*
Athlete Information
Athlete's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Athlete's Age
Sex assigned at birth*

MaleFemale
How do you identify your gender?*

MaleFemaleOther
Athlete's Grade*
Athlete's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Athlete's Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have insurance?*

No, I do not have insurance ( I will pay the $40 fee)Yes, I have insurance
Insurance Company Name (This information is needed in case of emergency)
Policy Number
Group Number
Insurance Phone Number
Insurance Company Name*

BlueCare/Tenncare Select (Tenncare)Wellpoint (Tenncare)United Healthcare Community Plan (Tenncare)AmBetterOther Insurance Company
Card Holder's Name

First NameLast Name
Card Holder's Date of Birth

MonthDayYear
Date
Insurance Card Proof*

I will take a picture of my insurance cardI will upload a picture of my insurance card
Take Picture of Insurance Card*
Upload Photo of Insurance Card*

Cancelof
Sign to change your child's PCP for this service today only. This is for Sports Physical billing (BlueCare/Tenncare Select)*
Sign to change your child's PCP for this service today only. This is for Sports Physical billing (Wellpoint)*
Sign to change your child's PCP for this service today only. This is for Sports Physical billing (Wellpoint)*
Sign to change your child's PCP for this service today only. This is for Sports Physical billing (AmBetter)*
Mother's Name*

First NameLast Name
Mother's Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Email Address
example@example.com
Father's Name*

First NameLast Name
Father's Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Father's Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father's Email Address
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to athlete*
Legal/Parent Consent
I/We hereby give consent for (athlete's name) First Name Last Name __________________________ to represent (name of school) ___________________________ in athletics realizing that such activity involves potential for injury. I/We acknowledge that even with the best coaching, the most advanced equipment, and strict observation of the rules, injuries are still possible. On rare these injuries are severe and result in disability, paralysis, and even death. I/We futher grant permission to the school and TSSAA, its physicians, athletic trainers, and/or EMT to render aid, treatment, medical, or surgical care deemed reasonably necessary to the health and well being of the student athlete named above during or resulting from participation in athletics. By the execution of this consent, the student athlete named above and his/her parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete during the course of the pre-participation examination by those performing the evaluation, and to the taking of medical history information and the recording of that history and the findings and comments pertaining to the s parent or student athlete on the forms attached hereto by those practitioners performing the examination. As parent or legal Guardian, I/We remain fully responsible for any legal responsibility which may result from any personal actions taken by the above named student athlete.
This form should be placed into the athlete's medical file and should not be shared with schools or sports organizations. The Medical Eligibility Form is the only form that should be submitted to a school or sports organization. Disclaimer: Athletes who have a current Preparticipation Physical Evaluation (per state and local guidance) on file should not need to complete another History Form.
PREPARTICIPATION PHYSICAL EVALUATION (Interim Guidance)
HISTORY FORM
List the sport(s) the athlete is participating in*
Have you ever had COVID-19?*

YesNo
Have you been immunized for COVID-19?*

YesNo
List past and current medical conditions.*
Have you ever had surgery? If yes, list all past surgical procedures.
Have you ever had surgery?
What type of surgery?*
When was the surgery? Month and Year*
Are you taking any prescriptions, over-the-counter medications, herbal supplements, and/or nutritional supplements?*
List all current prescriptions, over-the-counter medications, herbal supplements, and/or nutritional supplements.*
Do you have any allergies?*
I am allergic to:*
Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Options: 0 Not at all, 1 Several days, 2 Over half the days, 3 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*
(A sum of >3 is considered positive on either subscale [question 1 and 2, or questions 3 and 4] for screening purposes.
Health Questions

An explaination is required for any "Yes" answers
1. Do you have any concerns about that you would like to discuss with your provider?*

YesNo
Please explain 1*
2. Has a provider ever denied or restricted your participation in sports for any reason?*

YesNo
2a. When (Month and Year)

MonthDayYear
Date
2b. Please explain 2*
3. Do you have any ongoing medical issues or recent illness?*

YesNo
Please explain 3*
4. Have you ever passed out or nearly passed out during or after exercise?*

YesNo
Please explain 4*
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*

YesNo
Please explain 5*
6. Does your heart ever race, flutter in your chest, or skip beats ( irregular beats) during exercise?*

YesNo
Please explain 6*
7. Has a doctor ever told you that you have any heart problems?*

YesNo
Please explain 7*
8. Has a doctor ever requested a test for your heart? (e.g., ECG or echocardiography)*

YesNo
8a. When? (Month and Year)*
8b. Are you being followed by or recommended to see a hear doctor?*
9. Do you get light-headed or feel shorter of breath than your friends during exercise?*

YesNo
Please explain 9*
10. Have you ever had a seizure?*

YesNo
10a. When (Month and Year)*
10b. Are you being followed by a neurologist?*
10c. Are you taking any seizure medications?*
11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years? (Including drowning or an unexplained car crash)*

YesNo
Please explain 11*
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, Catecholaminergic polymorphic ventricular tachycardia (CPVT)?*

YesNo
Please explain 12*
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?*

YesNo
Please explain 13*
14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that cause you to miss a practice or game?*

YesNo
Please explain 14*
When? (Month and Year)*
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?*

YesNo
Please explain 15*
16. Do you cough, wheeze, or have difficulty breathing during or after exercise?*

YesNo
Please explain 16*
17. Are you missing a kidney, an eye, a testicle (male), your spleen, or any other organ?*

YesNo
Please explain 17*
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*

YesNo
Please explain 18*
19. Do you have any recurring skin rashes or rashes that come and go including herpes or MRSA?*

YesNo
Please explain 19*
20. Have you had a concussion or head injury that caused confusion, a prolong headache, or memory problems?*

YesNo
Please explain 20*
21. Have you ever had numbness, tingling, or weakness in your arms or legs, or been unable to move them after falling or being hit?*

YesNo
Please explain 21*
22. Have you ever become ill while exercising in the heat?*

YesNo
Please explain 22*
23. Do you or does someone in your family have sickle cell trait or disease?*

YesNo
Please explain 23*
24. Have you ever had or do you have any problems with your eyes or vision?*

YesNo
Please explain 24*
25. Do you worry about your weight?*

YesNo
Please explain 25*
26. Are you trying to or has anyone recommended that you gain or lose weight?*

YesNo
Please explain 26*
27. Are you on a special diet or do you avoid certain types of foods or food groups?*

YesNo
Please explain 27*
28. Have you ever had an eating disorder?*

YesNo
Please explain 28*
29. Have you ever had a menstrual period?*

YesNo
30. How old were you when you had your first menstrual period?*
31. When was your most recent menstrual period?*

MonthDayYear
Date
32. How many periods have you had in the last 12 months?*
If you have any addtional information that the medical provider needs to be aware of, please list it below.
Do you suffer from:*

AsthmaDiabetesEpilepsyHeart Condition(s)Sickle Cell TraitI do not suffer from any of these
Do you wear contacts?*
Do you have any illnesses not listed above?
If your athlete has a release or approval to participate from a specialist or other provider, please take a photo or upload the approval documents below.
Take a photo of approval documents
Upload approval documents

Cancelof
⚠️ By continuing, you accept that your electronic signature is as valid as a handwritten signature and will be treated as original under applicable law.
Signature of Athlete*
Signature of Parent/Guardian*
Date

MonthDayYear
Date
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.
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CONSENT FOR ATHLETIC PARTICIPATION & MEDICAL CARE

Athlete Information

Legal/Parent Consent

PREPARTICIPATION PHYSICAL EVALUATION (Interim Guidance)

HISTORY FORM

Patient Health Questionnaire Version 4 (PHQ-4)

Health Questions