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Preparticipation Sports Physical Evaluation

Complete the form below prior to meeting with your provider for sports participation evaluation.
If you prefer to print and complete a hardcopy to turn in, you may do so here.

Preparticipation Physical Evaluation

History

Birthday
Month
Day
Year
Evaluation Date
Month
Day
Year
Sex Assigned at Birth:
Male
Female
How do you identify your gender?
Male
Female
Non-Binary
Other
Have you had Covid - 19?
Yes
No
If yes, have you had:
One shot
Two shots
Three shots
Booster Dates:

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious or on edge
Not at all
Several Days
Over half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several Days
Over half the days
Nearly every day
Little interest or pleasure from doing things
Not at all
Several Days
Over half the days
Nearly every day
Little interest or pleasure from doing things
Not at all
Several Days
Over half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several Days
Over half the days
Nearly every day

(A sum of >3 is considered positive on either subscale (questions 1 and 2, or questions 3 and 4) for screening purposes.)

General Questions

Explain "Yes" answers at the end of this form.

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

Heart Health Questions

Have you ever passed out or nearly passed out during or after exercise?
Yes
No
Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
Yes
No
Has a doctor ever told you that you have any heart problems?
Yes
No
Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
Yes
No
Do you get light-headed or feel shorter of breath than your friends during exercise?
Yes
No
Have you ever had a seizure?
Yes
No
Has any family member or relative died of heart problems or had an unexpected or unexplained death before age 35 years (including drowning or unexplained car crash)?
Unsure
Yes
No

Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QTsyndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?

Unsure
Yes
No
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?
Unsure
Yes
No

Bone and Joint Questions

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

Medical Questions

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

Menstrual Questions

Have you ever had a menstrual period?
Not Applicable
Yes
No

"Yes" Answers Explained

Signatures

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

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Date Completed
Month
Day
Year
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