Sports Medicine Essentials, 3e - 25

CHAPTER 2

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Legal Considerations and Administration

Name _____________________________________________ Age ________ Sex ________ Date of Birth ______________________
Address ___ ________________________________________________________________ Phone ___________________________
City __________________________________________________ State ___________________ Zip ___________________________
School _________________________________________Grade ________ Sport(s) ________________________________________
Height ________ Weight ________ Personal Physician ____________________________ Physician's Phone ____________________
Complete this form (including signatures) before your examination. Include dates of any problems and explain all "Yes" answers below.
Yes No

1. Are you currently under a doctor's care for any reason?...............
2. Have you ever been hospitalized?.................................................
3. Have you ever had surgery?..........................................................
4. Are you currently taking any medications or pills?.........................
5. Do you have any allergies (medicines, bee stings, etc.)?..............
6. Have you ever been dizzy or fainted during or after exercise?......
7. Have you ever had chest pain during or after exercise?................
8. Have you ever had high blood pressure?......................................
9. Have you ever been told that you have a heart murmur?..............
10. Have you ever had racing of your heart or skipped heartbeats? ..
11. Have you ever had a head injury? ................................................
12. Have you ever been knocked out or unconscious? ......................
13. Have you ever had a seizure? ......................................................
14. Have you ever had a stinger, burner or pinched nerve?...............
15. Have you ever been dizzy or passed out in the heat?..................
16. Do you have trouble breathing during or after exercise?..............
17. Do you have any skin problems (itching, rashes, etc.)? ...............
18. Have you had any problems with your eyes or vision?.................
19. Do you wear glasses or contacts or protective eye wear? ...........
20. Do you use any special equipment (splints, neck rolls,
mouth guards, etc.?.......................................................................

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Yes No

21. Has anyone in your family died of heart
problems or sudden death before age 50?...................................
22. Do you have only one working organ of usually
paired organs (only one eye, kidney, etc.)? ..................................
23. Have you ever sprained, broken, dislocated or had
repeated swelling or pain of any bones or joints?.........................
Head ❑ Neck ❑ Chest ❑ Shoulder ❑ Back ❑
Hand ❑ Wrist ❑ Elbow ❑ Forearm ❑ Hip ❑
Thigh ❑ Knee ❑ Ankle ❑ Shin/Calf ❑ Foot ❑
24. Are any of these bothering you currently? ....................................
25. Have you had any other medical problems?
(asthma, mono, diabetes, etc.) .....................................................
26. Have you had any medical problems or injuries
since your last evaluation? ...........................................................
27. Were there any special instructions or precautions
given by the Medical Practitioner? ................................................
28. When was your last tetanus shot?............................................
29. Do you have Sickle Cell Trait or Sickle Cell Disease? ..................

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Explain all "Yes" answers by question number and indicate dates for each item (include any special instructions):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I/We hereby state that, to the best of my/our knowledge, the answers to the above questions are correct. I/We understand that by performing
this examination, the undersigned physician does not assume responsibility for the medical care of this individual. I/We hereby grant
consent to share this information to the sports medicine team (coach, athletic trainer, doctor, etc.).
Signature of Athlete _____________________________________________________________________ Date ______________________
Signature of Parent or Guardian (if athlete is under 18) ___________________________________________ Date ______________________
-------------------------------------------- DO NOT WRITE BELOW THIS LINE ------------------------------------------------Blood Pressure

HEENT

Skin

Heart

Lungs

Abdomen

Flexibility/Strength

NORMAL
ABNORMAL
While this does not constitute a complete physical examination nor replace the need for periodic health evaluations by a family physician,
this individual appears to be physically capable of participation in interscholastic sports as of this date, except as indicated below.
❑ Cleared for sports without restrictions
❑ Cleared with the following restrictions: ____________________________________________________________________________
❑ Cleared after completing evaluation/rehabilitation for: ________________________________________________________________
❑ Not Cleared
At this athlete's screening exam the following is/are noted:
Condition/Sign/Symptoms with Simple Explanation/Recommendations
❑ Elevated (High) Blood Pressure. Increase in pressures in the artery during the beating and resting heart . Maximum normal (age group)__/__
❑ Heart Murmur. Flow of blood through the heart which is audible. In this case, it is: ❑ "Functional" (normal) ❑ Abnormal.
❑ Asthma. Blockage of small airways in the lung . ❑ Use inhaler as prescribed and 30 minutes before exercise.
❑ Allergic Reactions to Stings or Bites. Whole body swelling & shortness of breath when stung or bitten. ❑ Epinephrine injector should be available at all times.
❑ Diabetes. Abnormal sugars and sugar metabolism. Continue close monitoring with M.D.
❑ Scoliosis. Curvature of the spine. ❑ Continue close monitoring with M.D.
❑ Orthopedic Problem. Being seen by M.D. for this condition ❑ Should be cleared for play by M.D.
❑ Concussion: Further evaluation required before athletic participation permitted.
❑ Other ______________________

Physician's Name _________________________ Physician's Signature _________________________ Date ____________________

2-4A | Sample Pre-Participation Physical Evaluation Form (front)

25



Table of Contents for the Digital Edition of Sports Medicine Essentials, 3e

Contents
Sports Medicine Essentials, 3e - Cover1
Sports Medicine Essentials, 3e - Cover2
Sports Medicine Essentials, 3e - A
Sports Medicine Essentials, 3e - B
Sports Medicine Essentials, 3e - i
Sports Medicine Essentials, 3e - ii
Sports Medicine Essentials, 3e - iii
Sports Medicine Essentials, 3e - iv
Sports Medicine Essentials, 3e - Contents
Sports Medicine Essentials, 3e - vi
Sports Medicine Essentials, 3e - vii
Sports Medicine Essentials, 3e - viii
Sports Medicine Essentials, 3e - ix
Sports Medicine Essentials, 3e - x
Sports Medicine Essentials, 3e - xi
Sports Medicine Essentials, 3e - xii
Sports Medicine Essentials, 3e - xiii
Sports Medicine Essentials, 3e - xiv
Sports Medicine Essentials, 3e - xv
Sports Medicine Essentials, 3e - xvi
Sports Medicine Essentials, 3e - xvii
Sports Medicine Essentials, 3e - xviii
Sports Medicine Essentials, 3e - xix
Sports Medicine Essentials, 3e - xx
Sports Medicine Essentials, 3e - 1
Sports Medicine Essentials, 3e - 2
Sports Medicine Essentials, 3e - 3
Sports Medicine Essentials, 3e - 4
Sports Medicine Essentials, 3e - 5
Sports Medicine Essentials, 3e - 6
Sports Medicine Essentials, 3e - 7
Sports Medicine Essentials, 3e - 8
Sports Medicine Essentials, 3e - 9
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Sports Medicine Essentials, 3e - 11
Sports Medicine Essentials, 3e - 12
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Sports Medicine Essentials, 3e - 14
Sports Medicine Essentials, 3e - 15
Sports Medicine Essentials, 3e - 16
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Sports Medicine Essentials, 3e - 19
Sports Medicine Essentials, 3e - 20
Sports Medicine Essentials, 3e - 21
Sports Medicine Essentials, 3e - 22
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Sports Medicine Essentials, 3e - 25
Sports Medicine Essentials, 3e - 26
Sports Medicine Essentials, 3e - 27
Sports Medicine Essentials, 3e - 28
Sports Medicine Essentials, 3e - 29
Sports Medicine Essentials, 3e - 30
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Sports Medicine Essentials, 3e - 60
Sports Medicine Essentials, 3e - 61
Sports Medicine Essentials, 3e - Cover4
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