Participation Physical History Preparticipation Physical History 2023 Sports Pre-participation History Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Confirm Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Enter a confirmation email address. Name * DOB * (MM/DD/YYYY) Date of Exam (MM/DD/YYYY) Biologic Sex * MaleFemale Sport(s) * Past & Current Medical Conditions Surgical History Medications and supplements Allergies Over the last 2 weeks have you experienced any of the following (check all that apply!) Feeling nervous, anxious, or on edge Not at all Several days Over half the days Nearly every day Not begin able to stop or control worrying Not at all Several days Over half the days Nearly every day Little interest or pleasure in 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 GENERAL QUESTIONS. Explain "Yes" answers. 1. Do you have any concerns that you would like to discuss with your provider? Yes No 2. Has a provider ever denied or restricted your participation in sports for any reason? Yes No 3. Do you have any ongoing medical issues or recent illness? Yes No HEART HEALTH QUESTIONS ABOUT YOU 4. Have you ever passed out or nearly passed out during or after exercise? Yes No 5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Yes No 6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? Yes No 7. Has a doctor ever told you that you have any heart problems? Yes No 8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography. Yes No 9. Do you get light-headed or feel shorter of breath than your friends during exercise? Yes No 10. Have you ever had a seizure? Yes No HEART HEALTH QUESITONS 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)? Yes No 12. 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 syndreme (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia (CPVT)? Yes No 13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35? Yes No BONE AND JOINT QUESTIONS 14. 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 15. Do you have a bone, muscle, ligament, or joint injury that bothers you? Yes No OTHER MEDICAL QUESTIONS 16. Do you cough, wheeze, or have diffculty breathing during or after exercise? Yes No 17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? Yes No 18. Do you have a groin or testicle pain or a painful bulge or hernia in the groin area? Yes No 19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)? Yes No 20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? Yes No 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? Yes No 22. Have you ever become ill while exercising in the heat? Yes No 23. Do you or does someone in your family have sickle cell trait or disease? Yes No 24. Have you ever had or do you have any problems with your eyes or vision? Yes No 25. Do you worry about your weight? Yes No 26. Are you trying to or has anyone recommended that you gain or lose weight? Yes No 27. Are you on a special diet or do you avoid certain types of foods or food groups? Yes No 28. Have you ever had an eating disorder? Yes No Explain all Yes answers Briefly, explain all "Yes" answers here (256 character maximum). Signature of athlete signature keyboard Clear Signature of parent or guardian signature keyboard Clear Date * (MM/DD/YYYY) Submit If you are human, leave this field blank.
