ICSA Sports Physical Examination

Transcription

1 Learning and Leading in a Collaborative Culture ICSA Sports Physical Examination (Circle One) MALE FEMALE What Sport do you plan to play? Student s Name: Date of Birth: M D Y Age: Grade / Class Address: Phone: Emergency Contact Instructions: Please review all questions below and answer them as truthfully as possible. It is important to include all pertinent information. Parents or guardians must sign below. GENERAL QUESTIONS 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify: Asthma Sickle Cell Anemia Allergies Diabetes Other 3. Have you ever had surgery?

2 HEART HEALTH QUESTIONS ABOUT YOU 4. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 5. Has a doctor ever told you that you have any heart problems? Yes No circle all that apply: High blood pressure A heart murmur High cholesterol A heart infection Other: 6. Have you ever passed out or nearly passed out DURING or AFTER exercise? 7. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram) 8. Do you get lightheaded or feel more short of breath than expected during exercise? 9. Have you ever had an unexplained seizure? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 10. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50? 11. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? 12. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

3 BONE AND JOINT QUESTIONS 13. Have you ever had any broken or fractured bones or dislocated joints? 14. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? 15. Do you regularly use a brace, orthotics, or other assistive device? 16. Do you have a bone, muscle, or joint injury that bothers you? 17. Do you have any history of juvenile arthritis or connective tissue disease? MEDICAL QUESTIONS 18. Have you ever had a head injury or concussion? 19. Do you cough, wheeze, or have difficulty breathing during or after exercise? 20. Have you ever used an inhaler or taken asthma medicine? 21. Do you have groin pain or a painful bulge or hernia in the groin area? 22. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

4 23. Do you get frequent muscle cramps when exercising? 24. Do you consider your current weight ideal? If no, write your ideal weight. 25. Have you ever had an eating disorder? 26. Do you take medication regularly? Yes No Please List FOR GIRLS ONLY: 27. How old were you when you had your first period? 28. Do you have regular periods? 29. How many periods did you have during the last 12 months? I have reviewed the above questions with my son or daughter and I give permission for my child to undergo the Pre-participation Physical Examination and to participate in team sports at ICSA during the school year. Signature of Student: Signature of Parent or Guardian: Date:

5 PRE-PARTICIPATION PHYSICAL EXAMINATION Student s Name: Date of Birth: Month Day Year PHYSICIAN REMINDERS 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? 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? PHYSICAL EXAMINATION Physician conducting the examination must complete all the information below Weight: Vision: (R) 20/ (L) 20/ Height: BP: Corrected Y/N (circle one) Cardiopulmonary Examination: Normal Abnormal (Explain) LUNGS PULSES HEART

6 Musculoskeletal Screening: Normal Abnormal (Explain) NECK SHOULDER ELBOW FOREARM WRIST HAND FINGERS BACK ANKLE

7 FOOT/TOES Other: (Physical examination pertinent to historical information) Recommendation: 1. Pass Sports Examination: 2. Pass with restrictions: 3. Deferred until: 4. Failed, Reason: I have examined the above named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. Physician name: