2026 Preparticipation Physical Evaluation

2026 Preparticipation Physical Evaluation

Note: Complete and sign this form (with your parents if younger than 18) before your appointment. If the appointments below do not work for you, please call our registration department to be scheduled at a different time. 608-873-6611
Which location will you be seen at?
Oregon Appointment Schedule
McFarland Appointment Schedule
Stoughton Appointment Schedule
Cottage Grove Appointment Schedule
Student-Athlete's Full Name

First NameMiddle InitialLast Name
Student-Athlete's Date of birth

MonthDayYear
Date
Student-Athlete's Age

Rows	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

Rows	Yes	No
Do you have any concerns that you would like to discuss with your provider?
Has a provider ever denied or restricted your participation in sports for any reason?
Do you have any ongoing medical issues or recent illness?

Rows	Yes	No
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 (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 light-headed or feel shorter of breath than your friends during exercise?
Have you ever had a seizure?

Rows	Yes	No
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 unexplained car crash)?
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 poly-morphic ventricular tachycardia (CPVT)?
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

Rows	Yes	No
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?
Do you have a bone, muscle, ligament, or joint injury that bothers you?

Rows	Yes	No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
Are you missing a kidney, an eye, a testicle(males), your spleen, or any other organ?
Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
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?
Have you ever become ill while exercising in the heat?
Do you or does someone in your family have sickle cell trait or disease?
Have you ever had, or do you have any problems with your eyes or vision?
Do you worry about your weight?
Are you trying to or has anyone recommended that you gain or lose weight?
Are you on a special diet or do you avoid certain types of foods or food groups?
Have you ever had an eating disorder?