Ohio State High School League
Student Name: _________________________________ Birth Date: __________ Age:____ Gender: M / F
Address:__________________________________________ ____________________________________________
Home Telephone: _____ -_____ -________
School: ______________________________ Grade: ____ Sports: ___________________________________
I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check One Box)
(1) Participate in all school interscholastic activities without restrictions.
(2) Participate in any activity not noted below.
(3) Requires further evaluation before a final recommendation can be made.
Additional recommendations for the school or parents: _____________________________________________
(4) Not cleared for:
All Sports Specific Sports____________________________________________
Reason: __________________________________________________ ________________________________
I have examined the above named student and completed the Sports Qualifying Physical Exam as required by the Ohio State High School League.
A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents.
Attending Physician Signature:________________________________________ _______ Date of Exam:__________
Print Physician Name: ___________________________________
Address: ______________________________________________
Office Telephone: _____ -_____ -________
SCHOOLYEAR 2007-2008 IS AFTER JUNE 15,2007
PHYSICIAN MUST SIGN AND DATE PHYSICAL EXAM FORM.
IMMUNIZATIONS [tD (required by age 14 or entry to 9th grade) ; MMR (2 required); hep B (3 required); varicella (or history of disease); poliomyelitis;
influenza]
Up-to-date (see attached school documentation)
Not up-to-date / Specify________________________________
IMMUNIZATIONS GIVEN TODAY: __________________________________________________ ___________________
EMERGENCY INFORMATION
Allergies_________________________________________ _______________________________________
__________________________________________________ ______________________________
Other Information_______________________________________ _________________________________________
__________________________________________________ ______________________________
Emergency Contact:____________________________________ Relationship _________________________
Telephone: (H) _____ -_____ -________ (W) _____ -_____ -________ (C) _____ -_____ -________
Personal Physician____________________________________ Office Telephone _____ -_____ -________
Reference: Preparticipation Physical Evaluation (Third Edition): AAFP, AAP, AMSSM, AOSSM, AOASM ; McGraw-Hill, 2005.
Student Name:_________________________________ Birth Date: __________ Age:____ Gender: M / F
Address:__________________________________________ ____________________________________________
Home Telephone: _____ -_____ -________
School: ______________________________ Grade: ____ Sports: ___________________________________
History
Circle Y for Yes or N for No Circle Question Number ( 1. etc) of questions for which the answer is unknown.
1. Has a doctor ever denied or restricted your participation in sports for any reason or told you to give up sports?.. Y / N
2. Do you have an ongoing medical condition (like diabetes or asthma)? ............. Y / N
3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills? ...................... Y / N
List: __________________________________________________ __________________________________________________ __________
4. Do you have allergies to medicines, pollens, foods, or stinging insects?........... Y / N
5. Have you ever passed out or nearly passed out DURING exercise?................ Y / N
6. Have you ever passed out or nearly passed out AFTER exercise? ................... Y / N
7. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?................................... Y / N
8. Does your heart race or skip beats during exercise?......................................... Y / N
9. Has a doctor ever told you that you have? (circle): High blood pressure A heart murmur High cholesterol A heart infection Rheumatic fever
10. Has a doctor ever ordered a test for your heart? (for example, ECG, echocardiogram, stress test)..................... Y / N
11. Has anyone in your family died suddenly and unexpectedly for no apparent reason?.......................................... Y / N
12. Does anyone in your family have a heart problem?......................................... Y / N
13. Has any family member or relative died of heart problems or of sudden death before age 50?........................... Y / N
14. Has anyone in your family less than 50 years old had unexplained drowning while swimming or an unexplained car accident? ............................. Y / N
15. Does anyone in your family have Marfan syndrome? ...................................... Y / N
16. Have you ever spent the night in a hospital? .................................................. . Y / N
16a. If Y, Explain ________________________________________________
17. Have you ever had surgery?....................... Y / N
17a. If Y, Explain ________________________________________________
18. Have you ever had an injury, like a sprain, muscle or ligament tear or tendonitis that caused you to miss a practice or game? .............................. Y / N
19. Have you had any broken or fractured bones, or dislocated joints?................ Y / N
20. Have you had a bone/joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? Y / N
If Yes in Questions 18, 19 or 20, please circle the area below:
Head Neck Shoulder Chest Upper Arm Elbow Forearm Hand/Fingers Upper Back Lower Back Hip Thigh Knee Calf/Shin Ankle Foot/Toes
21. Have you ever had a stress fracture?......... Y / N
22. Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?............................ Y / N
23. Do you regularly use a brace or assistive device?........................................... Y / N
24. Has a doctor ever told you that you have asthma or allergies?....................... Y / N
25. Do you cough, wheeze, chest tightness, or have difficulty breathing during or after exercise? ............................ Y / N
26. Is there anyone in your family who has asthma? ............................................. Y / N
27. Have you ever used an inhaler or taken asthma medicine?............................ Y / N
28. Do you develop a rash or hives when you exercise?....................................... Y / N
29. Were you born without or are you missing a kidney, an eye, a testicle, or any other organ?................................ Y / N
30. Have you had infectious mononucleosis (mono) within the last month?.......... Y / N
31. Do you have any rashes, pressure sores, or other skin problems?................. Y / N
32. Have you had a herpes skin infection? ...... Y / N
33. Have you ever had a head injury or concussion? ............................................ Y / N
34. Have you been hit in the head and been confused or lost your memory? ....... Y / N
35. Have you ever had a seizure? .................... Y / N
36. Do you have headaches with exercise?..... Y / N
37. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? ................... Y / N
38. Have you ever been unable to move your arms or legs after being hit or falling? ................................................. Y / N
39. When exercising in the heat, do you have severe muscle cramps or become ill?.............................................. ... Y / N
40. Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?................... Y / N
41. Have you had any problems with your eyes or vision? .................................... Y / N
42. Do you wear glasses or contact lenses?.... Y / N
43. Do you wear protective eyewear, such as goggles or a face shield?.............. Y / N
44. Are you happy with your weight? ................ Y / N
45. Are you trying to gain or lose weight?......... Y / N
46. Has anyone recommended you change your weight or eating habits?............ Y / N
47. Do you limit or carefully control what you eat?.............................................. ... Y / N
48. Do you get tired more quickly than your friends do during exercise?.............. Y / N
49. Do you have any concerns that you would like to discuss with a doctor? ........ Y / N
FEMALES ONLY
50. Have you ever had a menstrual period? .... Y / N
51. How old were you when you had your first menstrual period? yy_____ mm_____
52. How many menstrual periods have you had in the last year? _____
MALES ONLY
53. How old were you when you first noticed pubic hair? yy_____ mm_____
54 Have you ever had a nocturnal emission or other ejaculation? .................................... Y / N
55. How old were you when you had your first nocturnal emission or other ejaculation? yy_____ mm_____
Notes: __________________________________________________ _________________________________________
I do not know of any existing physical or additional health reason that would preclude participation in sports. I certify that the answers to the above questions are true and accurate and I approve participation in athletic activities.
Parent/Guardian Signature ________________________________ Date ____________________
Follow-Up Questions About More Sensitive Issues:
1. Do you feel stressed out or under a lot of pressure?
2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days?
3. Do you feel safe?
4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke?
5. During the past 30 days, did you use chewing tobacco, snuff, or dip?
6. During the past 30 days, have you had at least 1 drink of alcohol?
7. Have you ever taken steroid pills or shots without a doctor's prescription?
8. Have you ever taken any supplements to help you gain or lose weight or improve your performance?
9. Are you concerned about puberty or any other part of your body that you would like to talk with a doctor about?
10. Question "Risk Behaviors" like guns, seatbelts, unprotected sex, domestic violence, drugs, and others.
Notes About Follow-Up Questions:
MEDICAL EXAM
Height _______ Weight ________ BMI _______ % Body fat ______ Arm Span_________ Foot Length _________
Pulse ___________ BP _______ /________ ( _______/ ______ )
Vision: R 20/____ L 20/____ Corrected: Y / N Contacts: Y / N Hearing: R____ L____ (Audiogram or confrontation)
Exam Normal Abnormal Notes Initials*
Appearance Y / N
Skin Y / N
HEENT
Eyes Y / N
Fundoscopic Y / N
Pupils Equal / Unequal
Ears/Nose Y / N
Hearing Y / N
Throat Y / N
Dental Y / N
Lymph Nodes Y / N
Thyroid Y / N
Heart Y / N
Murmurs Y / N
Pulses Y / N
Lungs Y / N
Abdomen Y / N
Genitourinary (Male)
Left Testicle present? Y / N
Right testicle present? Y / N
Circumcised Y / N
If no, foreskin retractable? Y / N
Hypospadias Y / N
Hernia Y / N
Tanner Staging ( I )( II )( III )( IV )( V )
Pubic Hair Staging ( I )( II )( III )( IV )( V )
Genitourinary (Female)
Breast Tanner Staging ( I )( II )( III )( IV )( V )
Genital Tanner Staging ( I )( II )( III )( IV )( V )
Pubic Hair Staging ( I )( II )( III )( IV )( V )
Musculoskeletal
Neck Y / N
Back Y / N
Shoulder/Arm Y / N
Elbow/Forearm Y / N
Wrist/Hand/Fingers Y / N
Hip/Thigh Y / N
Knee Y / N
Leg/Ankle Y / N
Foot/Toes Y / N
Duck Walk Y / N
Notes:
Assessment:
Physical validity period: Annual Bi-Annual Triennal
Next Physical Due: mm____ yy____
Plan:
Immunizations: Up-to-Date Immunize if needed (Required by age 14 or entry to 9th grade: DTaP series plus tD with Pertusis,
4 HIB, 2MMR, 3 HBV, 4 IPV)
Consider Flu Shot (Asthma, winter athletes)
Health maintenance: Lifestyle, health, and safety counseling
Discussed dental care and mouthguard use
Discussed Lead and TB exposure - (Testing indicated / not indicated)
Revised 6/1/07 |
