2026-2027 PRE-PARTICIPATION PHYSICAL

IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION

2026-2027
Please complete and sign this form (with your parents if younger than 18) before your appointment.
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Date of Examination:

MonthDayYear
Date
Sport(s):
Home Address (Street, City, State, Zip):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School District:
Parent's/Guardian's Name:

First NameLast Name
Phone #:
Format: (000) 000-0000.
Physician:
Phone #:
Format: (000) 000-0000.
History Form:
List past and current medical conditions.
Have you ever had a surgery? If "yes", list all past surgical procedures.
List all current prescriptions, over-the-counter medicines and supplements (herbal and nutritional) that you are taking.
Do you have any allergies? If yes, please list all your allergies (to medicines, pollen, food, stinging insects, etc.)

PHQ-4: Over the last 2 weeks, how often have you been bothered by any of the following problems? (Put an x in the column that best describes your feelings.)

Rows	Not at all - 0	Several Days - 1	Over half the days - 2	Nearly Everyday - 3
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

SCORE:
General Questions:
In the section below, if you answer "yes" to any questions, please explain further in the space provided at the end of this form.
Do you have any concerns that you would like to discuss with your provider?
Has a provider ever denied or restricted your participation in sport for any reason?
Do you have any ongoing medical issues or recent illnesses?
Heart Health Questions:
Have you ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?
Does your heart ever race, flutter in your chest or skip beats (have irregular beats) during exercise?
Has a doctor ever told you that you have any heart problems?
Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography?
Do you get lightheaded or feel shorter of breath more quickly than your friends during exercise?
Do you have high blood pressure or high cholesterol?
If you answer "yes" to any questions, please explain further in the space provided.
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Medical Eligibility Form
Consent (to be filled out by parent/guardian)
Student Athlete Name:
Date of Birth:

MonthDayYear
Date
Date of Examination:

MonthDayYear
Date
I acknowledge and give consent for a copy of this form to be kept in the student's school health record and shared with the school in the event that additional medical information is needed/appropriate. Should my student's health change in any way that would impact information in this form and/or participation, I will inform the school as soon as possible.
Consent to release form
Signature of Parent or Guardian:
Date:

MonthDayYear
Date
* I understand that I may be asked to release additional health information to the school if needed.
Shared Emergency Information (To be filled out by athlete/athlete's caregiver)
Student Athlete's Allergies:
Student Athlete's Medications:

Emergency Contacts:

Rows	Name	Relationship	Contact Information
1
2
3

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Should be Empty:

IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION

History Form:

General Questions:

Heart Health Questions:

Questions about your Family:

Bone and Joint Questions:

Medical Question:

FEMALES only:

Medical Eligibility Form

Consent (to be filled out by parent/guardian)

Shared Emergency Information (To be filled out by athlete/athlete's caregiver)