Pediatric Sports Physical Evaluation Form - English

  • Please Select the Clinic You Are Scheduled With:

  • Pediatrics (A - North Plaza)

    Location: A - North Plaza, Entrance A3 on RRH.org/map

    Pediatrics (Southern Sierra Medical Clinic)

    Location: G - East Plaza, Entrance G1 on RRH.org/map

  • PRE-PARTICIPATION PHYSICAL EVALUATION (Interim Guidance)

  • 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.

  • HISTORY FORM

  • Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
  • Date of birth:*
     - -
  • Have you had COVID-19? (check one):*
  • Have you been immunized for COVID-19? (check one):*
  • If yes, have you had:
  • Rows

  • General Questions

    Explain "Yes" answers at the end of this form. Leave blank if you do not know the answer.
  • 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 illness?*

  • Heart Health Questions About You

  • 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.*
  • 9. Do you get light-headed or feel shorter of breath than your friends during exercise?*
  • 10. Have you ever had a seizure?*

  • Heart Health Questions About Your Family

  • 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 unexplained car crash?)*
  • 12. Does anyone in your family have genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LGTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?*
  • 13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?*

  • Bone and Joint Questions

  • 14. Have you ever had a stress fracture or n injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?*
  • 15. Do you have a bone, muscle, ligament, or joint injury that bothers you?*

  • Medical Questions

  • 16. Do you cough, wheeze, or have difficulty breathing during or after exercise?*
  • 17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?*
  • 18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*
  • 19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?*
  • 20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?*
  • 21. 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?*
  • 22. Have you ever become ill while exercising in the heat?*
  • 23. Do you or does someone in your family have sickle cell trait or disease?*
  • 24. Have you ever had or do you have any problems with your eyes or vision?*
  • 25. Do you worry about your weight?*
  • 26. Are you trying to or has anyone recommended that you gain or lose weight?*
  • 27. Are you on a special diet or do you avoid certain types of foods or food groups?*
  • 28. Have you ever had an eating disorder?*

  • Females Only

  • 29. Have you ever had a menstrual period?
  • I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
  • 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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