OLD TAPPAN BOARD OF EDUCATION FILE CODE: / Old Tappan, NJ INTRAMURAL/INTERASCHOLASTIC COMPETITION
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1 OLD TAPPAN BOARD OF EDUCATION FILE CODE: / Old Tappan, NJ INTRAMURAL/INTERASCHOLASTIC COMPETITION New Jersey Department of Education ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM Part A: HEALTH HISTORY QUESTIONNAIRE (To be completed by the parent and student) (Pursuant to N.J.A.C. 6A: 16 Programs to Support Student Development) Today s Date: Date of Last Sports Physical: Student s Name Sex: M F (circle one) Age Grade Date of Birth: School: District: Sports(s): Home Phone: ( ) Provider Name (Medical Home): Phone: Fax: EMERGENCY CONTACT INFORMATION Name of parent/guardian: Relationship to student; Phone (work): Phone (home): Phone (cell): Additional emergency contact: Relationship to student; Phone (work): Phone (home): Phone (cell): Directions: Please answer the following questions about the student s medical history by circling the correct response. Explain all yes responses at the bottom of the page. Please respond to all questions. 1. Have you had or do you currently have: a. Restriction from sports for a health-related problem? Y /N /Don t Know b. An injury or illness since your last exam? Y /N /Don t Know c. A chronic or ongoing illness (such as diabetes or asthma)? Y /N /Don t Know (1). Use an inhaler or other prescription medicine to control asthma? Y /N /Don t Know d. Any prescribed or over the counter medications that you take on a regular basis? Y /N /Don t Know e. Surgery, hospitalization or any emergency room visit(s)? Y /N /Don t Know f. Any allergies to medications? Y /N I Don t Know g. Any allergies to bee stings, pollen, latex or foods? Y /N /Don t Know (1). If yes, check type of reaction: Y /N /Don t Know Rash Hives Breathing or other anaphylactic reaction (2). Take any medication/epipen taken for allergy symptoms? (List below.) Y /N /Don t Know h. Any anemias or blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y /N /Don t Know i. A blood relative who died before age 50? Y /N /Don t Know Explain all yes answers here (include relevant dates): List all medications here: Medication Name Dosage Frequency Part A Page 1 of 3
2 2. Have you had or do you currently have any of the following head-related conditions: a. Concussion requiring a physician s evaluation? Y I N I Don t Know b. Memory loss Y I N I Don t Know c. Knocked out? Y /N I Don t Know c. A seizure? Y I N I Don t Know d. Frequent or sever head aches (With or without exercise)? Y I N I Don t Know e. Fuzzy or blurry vision Y I N I Don t Know f. Sensitivity to light/noise Y I N I Don t Know 3. Have you had or do you currently have any of the following heart-related conditions: a. Restriction from sports for heart problems? b. Chest pain or discomfort? Y I N I Don t Know c. Heart murmur? Y I N I Don t Know d. High blood pressure? Y I N I Don t Know e. Elevated cholesterol level? Y I N I Don t Know f. Heart infection? Y I N I Don t Know g. Dizziness or passing out during exercise without known cause? Y I N I Don t Know h. Has a provider ever ordered a heart teat (EKG, electrocardiogram, stress test, Holter monitor)? Y I N I Don t Know i. Racing or skipped heart beats? Y I N I Don t Know j. Unexplained difficulty breathing or fatigue during exercise? Y I N I Don t Know k. Any family member (blood relative): (1.) Under age 50 with a heart condition? Y I N I Don t Know (2.) With Marfan s Syndrome? Y I N I Don t Know (3.) Died of a hear problem before age of 50? If yes, what age? Y I N I Don t Know (4.) Died with no known reason? Y I N I Don t Know (5.) Died while exercising? If yes, was it during or after? (Circle one.) Y I N I Don t Know 4. Have you had or do you currently have any of the following eye, ear, nose, mouth or throat conditionsl: a. Vision problems? Y I N I Don t Know (1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.) Y I N I Don t Know b. Hearingloss or problems? Y I N I Don t Know (1.) Wear hearing aides or implants? Y / N / Don t Know c. Nasal fractures or frequent nose bleeds? Y / N / Don t Know d. Wear braces, retainer or protective mouth gear? Y / N / Don t Know e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)? Y I N I Don t Know 5. Have you had or do you currently have any of the following neuromuscular/orthopedic conditions: a. Numbness, a burner, stinger or pinched nerve? Y I N I Don t Know b. A sprain? Y I N I Don t Know c. A strain? Y I N I Don t Know d. Swelling or pain in muscles, tendons, bones or joints? Y I N I Don t Know e. Dislocated joint(s)? Y I N I Don t Know f. Upper or lower back pain? Y I N I Don t Know g. Fracture(s) or stress fracture(s)? Y I N I Don t Know h. Do you wear any protective braces or equipment for any prior injury? Y I N I Don t Know Part A Page 2 of 3
3 6. Have you had or do you currently have any of the following general or exercise related conditions: a. Difficulty breathing? Y I N I Don t Know (1). During Exercise? Y I N I Don t Know (2). After running one mile? Y I N I Don t Know (3).. Coughing, wheezing or shortness of breathe in weather changes? Y I N I Don t Know (4). Exercise-induced asthma? Y I N I Don t Know i. Controlled with medication? (Specify ) Y I N I Don t Know ii. Experience dizziness, passing out or fainting? Y I N I Don t Know b. Viral infections (e.g. mono, hepatitis, coxsackie, virus)? Y I N I Don t Know c. Become tired more quickly than others? Y I N I Don t Know d. Any of the following skin conditions: (1). Cold sores/herpes, impetigo, MRSA, ringworm, warts? Y I N I Don t Know (2). Sun sensitivity? Y I N I Don t Know e. Weight gain/loss (10 pounds or more)? Y I N I Don t Know (1). Do you want to weigh more or less than you do now? Y I N I Don t Know f. Ever had feelings of depression? Y I N I Don t Know g. Heat-related problems (dehydration, dizziness, fatigue, headache)? Y I N I Don t Know (1). Heat exhaustion (cool, clammy, damp skin)? Y IN I Don t Know (2). Heat stroke (hot, red, dry skin)? Y I N I Don t Know (3). Muscle cramps? Y I N I Don t Know 7. Femalesonly: Age of onset of menstruation: How many menstrual periods in the last twelve (12) months? 8. Males only: Have you had any swelling or pain in your testicles or groin? How many periods missed in the last twelve (12) months? Y I N I Don t Know PARENT /GUARDIAN SIGNATURE I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature. Signature, Parent/Guardian or Student Age 18 Date of Signature THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM. Part A Page 3 of 3
4 ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM Part B: Physical Examination (To be completed by the examining physician) STUDENT INFORMATION: Student s Name: Sport(s): Sex: M F (circle one) Age: Grade: Date of Birth: Address: City/State/Zip: Home Phone: School: District: Parent/Guardian s Full Name: -EXAMING PHYSICIAN/PROVIDER CONTACT INFORMATION: If conducted by school physician check here Name: Phone: Fax: Address: City/State/Zip: Height: Weight: Blood Pressure: / Pulse: bpm. Vision: R 20/ L 20/ Corrected: Y /N Contacts: Y/N Glasses: Y / N Indicators Normal? Abnormal Findings/Comments General Appearance Head/Neck Eyes/Sclera/pupils Ears Gross Hearing Nose/Mouth/Throat Lymph Glands Cardiovascular Heart rate Rhythm Murmur ABSENT If murmur present Standing makes it: Louder: Softer: No Change Squatting makes it: Louder: Softer: No Change Valsalva makes it: Louder: Softer: No Change Femoral Pulses Lungs: Auscultation/Percussion Chest Contour Skin Abdomen: (liver, spleen, masses Assessment of physical maturation or Tanner Scale Testicular Exam (Males Only) Neck/Back/Spine: Range of Motion: Scoliosis: ABSENT Upper Extremities: (ROM, Strength, Stability) Lower Extremities: (ROM, Strength, Stability) Neurological: Balance & Coordination: Hernia ABSENT Evidence of Marfan Syndrome ABSENT Part B Page 1 of 4
5 Most recent immunizations and dates administered: Medications currently prescribed, with dose and frequency: Medication Name Dosage Frequency Additional Observations: General Diagnosis: General Recommendations: THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION. Part B Page 2 of 4
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7 CLEARANCES: (See notes at bottom for conditions requiring attention and for a list of sports by level of contact) A. Student is cleared for participation in all sports without restriction. B. Student is withheld clearance for participation in any sport until evaluation / treatment of: C. Student is cleared for participation in limited types of sports which exclude the following types of sports contact: (CHECK ALL THAT APPLY) CONTACT/COLLISION LIMITED CONTACT NON-CONTACT/STRENUOUS NON-CONTACT/NON-STRENUOUS Due to: HISTORY REVIEWED AND STUDENT EXAMINED BY: Physician s/provider s Stamp: Primary Care Provider School Physician Provider License Type: MD/DO APN PA Physician s/provider s Signature Today s Date Date of Exam: HISTORY REVIEWED BY Name Signature: Today s Date: Review Date: RESERVED FOR SCHOOL DISTRICT USE Part B Page 3 of 4
8 NOTES TO THE EXAMINING PROVIDER Conditions requiring clearance before sports participation include, but are not limited to the following: Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension; Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye. SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT Contact/Collision Limited Contact Non-Contact Strenuous Non-strenuous Basketball Baseball Discus Bowling Diving Cheerleading Javelin Golf Field Hackey Fencing Shot put Football High Jump Rowing Ice Hockey Pole vault Running/Cross Country Lacrosse Gymnastics Strength Training Soccer Skiing Swimming Wrestling Softball Tennis Volleyball Track N.J.A.C. 6A: requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the student s participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the student s school health record. Effects of physiologic maneuvers on heart sounds: Standing Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole Squatting Increases murmur of AS, MR, Al Decreases murmur of MCH MVP click delayed Valsalva Increases murmur of HCM Decreases murmur of AS, MR MVP click occurs earlier in systole Physical Stigmata of Marfan s Syndrome Kyphosis High arched palate Pectus excavatum Arachnodactyly Arm span> height 1.05:1 or greater Mitral Valve Prolapse Aortic Insufficiency Myopia Lenticular dislocation HCM = Hypertrophic Cardio Myopathy AS= Aortic Stenosis Al = Aortic Insufficiency MR = Mitral Regugitation MVP = Mitral Valve Prolapse Part B Page 4 of 4 Approved: January 6, 2014
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