skip to main content


Name__________________________________________________ Sex ________ Age______ Date of birth _______________

Address ______________________________________________________________________ Phone______________________

School ________________________________________________________Grade __________ Sport ______________________


Preparticipation Physical Evaluation Form



Explain "Yes" answers below: Yes No

1. Has a doctor ever restricted/denied your participation in sports?

2. Have you ever been hospitalized or spent a night in a hospital?

Have ever had surgery?

3. Do you have any ongoing medical conditions (like Diabetes or Asthma)?

4. Are you presently taking any medications or pills (prescription or over‐the‐counter?

5. Do you have any allergies (medicine, pollens, foods, bees or other stinging insects)?

6. Have you ever passed out during or after exercise?

Have you ever been dizzy during or after exercise?

Have you ever had chest pain or discomfort in your chest during or after exercise?

Do you tire more quickly than your friends during exercise?

Have you ever had high blood pressure?

Have you ever been told that you have a heart murmur, high cholesterol, or heart infection?

Have you ever had racing of your heart or skipped heartbeats?

Has anyone in your family died of heart problems or a sudden death before age 50?

Does anyone in your family have a heart condition?

Has a doctor ever ordered a test on your heart (EKG, echocardiogram)?

7. Do you have any skin problems (itching, rashes, staph, MRSA, acne)?

8. Have you ever had a head injury or concussion?

Have you ever been knocked out or unconscious?

Have you ever had a seizure?

Have you ever had a stinger, burner, pinched nerve, or loss of feeling or weakness in your arms or legs?

9. Have you ever had heat or muscle cramps?

Have you ever been dizzy or passed out in the heat?

10. Do you have trouble breathing or do you cough during or after activity?

Do you take any medications for asthma (for instance, inhalers)?

11. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)?

12. Have you had any problems with your eyes or vision?

Do you wear glasses or contacts or protective eye wear?

13. Have you had any other medical problems (infectious mononucleosis, diabetes, infectious diseases, etc.)?

14. Have you had a medical problem or injury since your last evaluation?

15. Have you ever been told you have sickle cell trait?

Has anyone in your family had sickle cell disease or sickle cell trait?

16. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other

injuries of any bones or joints?

Head Back Shoulder Forearm Hand Hip Knee Ankle

Neck Chest Elbow Wrist Finger Thigh Shin Foot

17. When was your first menstrual period?__________________________________________________________________

When was your last menstrual period?___________________________________________________________________

What was the longest time between your periods last year?________________________________________________

Explain "Yes" answers:






I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Signature of athlete ___________________________________________________________ Date ___________________

Signature of parent/guardian __________________________________________________ DUPLICATE AS NEEDED

Rev. 2010 FORM 5 Page 1 of 2- In order for a student to be eligible for interscholastic athletics, there must be

Preparticipation Physical Evaluation

Physical Examination

Rule 1, Sec. 14

on file in the Superintendent's or Principal's office a current physician's statement certifying that

the student has passed a physical exam, and that in the opinion of the examining physician (M.D.

or D.O.) the student is fully able to participate in interscholastic athletics (Grade s 7‐12). The

AHSAA Physicians Certificate (Form 5) must be used. A physical exam will satisfy the


A. Cleared

B. Cleared after completing evaluation/rehabilitation for: _______________________________________

C. Not cleared for: Collision


Noncontact ____ Strenuous ____ Moderately strenuous ____ Nonstrenuous

Due to: ____________________________________________________________________________________________

Recommendation: _________________________________________________________________________________________



Name of physician ________________________________________________________________ Date ____________________

Address ________________________________________________________________________ Phone___________________

Signature of physician _____________________________________________________________, M.D. or D.O.



Height ____________ Weight _____________ BP _____ / _____ Pulse ____________

Vision R 20 / ____ L 20 / ____ Corrected: Y N

Normal Abnormal Findings








Genitalia (males)












requirement for one calendar year through the end of the month from the date of the exam.

For example, a physical given on May 5, 2015, will satisfy the requirment through May 31, 2016.