IWU PPE Form-7
IWU PPE Form-7
IWU PPE Form-7
HISTORY FORM
(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies? Yes No If yes, please identify specific allergy below.
Medicines Pollens Food Stinging Insects
Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No
1. Has a doctor ever denied or restricted your participation in sports for 26. Do you cough, wheeze, or have difficulty breathing during or
any reason? after exercise?
2. Do you have any ongoing medical conditions? If so, please identify 27. Have you ever used an inhaler or taken asthma medicine?
below: Asthma Anemia Diabetes Infections 28. Is there anyone in your family who has asthma?
Other: ________________________________________________ 29. Were you born without or are you missing a kidney, an eye, a testicle
3. Have you ever spent the night in the hospital? (males), your spleen, or any other organ?
4. Have you ever had surgery? 30. Do you have groin pain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or 32. Do you have any rashes, pressure sores, or other skin problems?
AFTER exercise? 33. Have you had a herpes or MRSA skin infection?
6. Have you ever had discomfort, pain, tightness, or pressure in your 34. Have you ever had a head injury or concussion? If so, how many? ___
chest during exercise?
35. Have you ever had a hit or blow to the head that caused confusion,
7. Does your heart ever race or skip beats (irregular beats) during exercise? prolonged headache, or memory problems?
8. Has a doctor ever told you that you have any heart problems? If so, 36. Do you have a history of seizure disorder?
check all that apply:
High blood pressure A heart murmur 37. Do you have headaches with exercise?
High cholesterol A heart infection 38. Have you ever had numbness, tingling, or weakness in your arms or
Kawasaki disease Other: ______________________ legs after being hit or falling?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, 39. Have you ever been unable to move your arms or legs after being hit
echocardiogram) or falling?
10. Do you get lightheaded or feel more short of breath than expected 40. Have you ever become ill while exercising in the heat?
during exercise? 41. Do you get frequent muscle cramps when exercising?
11. Have you ever had an unexplained seizure? 42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends 43. Have you had any problems with your eyes or vision?
during exercise?
44. Have you had any eye injuries?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
45. Do you wear glasses or contact lenses?
13. Has any family member or relative died of heart problems or had an
46. Do you wear protective eyewear, such as goggles or a face shield?
unexpected or unexplained sudden death before age 50 (including
drowning, unexplained car accident, or sudden infant death syndrome)? 47. Do you worry about your weight?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan 48. Are you trying to or has anyone recommended that you gain or
syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT lose weight?
syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic 49. Are you on a special diet or do you avoid certain types of foods?
polymorphic ventricular tachycardia?
50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator? 51. Do you have any concerns that you would like to discuss with a doctor?
16. Has anyone in your family had unexplained fainting, unexplained FEMALES ONLY
seizures, or near drowning? 52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS Yes No 53. How old were you when you had your first menstrual period?
17. Have you ever had an injury to a bone, muscle, ligament, or tendon 54. How many periods have you had in the last 12 months?
that caused you to miss a practice or a game?
18. Have you ever had any broken or fractured bones or dislocated joints? Explain “yes” answers here - incomplete if left empty
19. Have you ever had an injury that required x-rays, MRI, CT scan,
injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete ___________________________________________ Signature of parent/guardian_ ____________________________________________________________ Date______________________
©2010 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.
HE0503 9-2681/0410
■ Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM
Name _ __________________________________________________________________________________ Date of birth ___________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues
• Do you feel stressed out or under a lot of pressure?
• Do you ever feel sad, hopeless, depressed, or anxious?
• Do you feel safe at your home or residence?
• Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
• During the past 30 days, did you use chewing tobacco, snuff, or dip?
• Do you drink alcohol or use any other drugs?
• Have you ever taken anabolic steroids or used any other performance supplement?
• Have you ever taken any supplements to help you gain or lose weight or improve your performance?
• Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (questions 5–14).
EXAMINATION
Height Weight Male Female
BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Y N
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/ears/nose/throat
• Pupils equal
• Hearing
Lymph nodes
Heart a
• Murmurs (auscultation standing, supine, +/- Valsalva)
• Location of point of maximal impulse (PMI)
Pulses
• Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
• HSV, lesions suggestive of MRSA, tinea corporis
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
• Duck-walk, single leg hop
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
a
©2010 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.
HE0503 9-2681/0410