The South Carolina Independent School Association

Pre-Participation History & Health Assessment Form

This form must be filled out online for school records. Please also make sure you bring the hardcopy of the Physical Exam form to the High School office with the doctors signature if you did not get a physical at school.

Date that this form is being completed:

Name: Date of Birth:

Grade: School:

Sex: Sports:

Address: Phone:

Personal Physician: Phone:

In Case of an Emergency Contact: Relationship:

Home Phone #: Cell #:

Other:

Attention parent or guardian and athlete: answers to the following questions are very important!
Please take the time to answer each question to the best of your knowledge.

Medicines and Allergies:
List all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are taking.

Do you have any allergies?YesNo

If yes, please identify specific allergy below.
MedicinesPollensFoodStinging InsectsOther
Please provide a description of cause and treatment:

Concussions

Have you ever had a head injury or concussion? YesNo
If yes, when (date):
Have you had more than one head injury or concussion? YesNo
If yes, how many?
Provide the date of each concussion:

Have you ever had a blow to the head that caused confusion, prolonged headache, or memory loss? YesNo

Parent’s Permission & Acknowledgement of Risk for Son or Daughter to Participate in Athletics
As the parent or legal guardian of the above named student athlete, I give my permission for his/her participation in athletic events and the physical evaluation for that participation. I grant permission for treatment deemed necessary for a condition arising during participation in these events, including medical or surgical treatment that is recommended by a medical doctor. I grant permission to nurses, trainers, coaches, doctors or those under their direction who are part of the athletic injury prevention or treatment, to have access to necessary medical information. I know that the risk of injury to my child/ward comes with participation in sports and during travel to and from play and practice. My signature indicates that to the best of my knowledge, my answers to the above questions are complete and correct.

Date:
Signature of athlete:

Date:
Signature of parent/guardian:

Pre-Participation Physical Evaluation Medical History Questionnaire

Note: This form is to be filled out by the parent(s) and student prior to seeing the physician.

Student’s Name: Today's Date:

Attention parent or guardian and athlete: answers to the following questions are very important! Please take the time to answer each question to the best of your knowledge. Explain “Yes” answers below. Circle question if you do not know the answer.

General Questions

1. Has a doctor ever denied or restricted your participation in sports for any reason? YesNo
2. Do you have any ongoing medical conditionsYesNo
If so Identify: AsthmaAnemiaDiabetesInfections
Other:
3. Have you ever spent the night in the hospital? YesNo
4. Have you ever had surgery? YesNo

Heart Heath Questions About You

5. Have you ever passed out or nearly passed out during or after exercise? YesNo
6. Have you ever had pain, discomfort, tightness, or pressure in your chest during exercise? YesNo
7. Does your heart ever race or skip a beat (irregular beats) during exercise? YesNo
8. Has a doctor ever told you that you have any heart problems? YesNo
If so, check all that apply:
High Blood PressureA heart murmurHigh cholesterolA heart infectionKawasaki disease
Other:
9. Has a doctor ever ordered a test for your heart? YesNo
10. Do you get lightheaded or feel more short of breath more than expected during exercise? YesNo
11. Have you ever had an unexplained seizure? YesNo
12. Do you get more tired or short of breath more quickly than your friends during exercise? YesNo

Health Questions About Your Family

13. Has any family member or relative died of heart problems or had an unexpected sudden death before age 50 (including drowning, unexplained car accident, sudden death syndrome)? YesNo
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic, polymorphic ventricular tachycardia? YesNo
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? YesNo
16. Has anyone in your family had unexplained fainting, unexplained seizures or near drowning? YesNo

Bone and Joint Questions

17. Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a game or practice? YesNo
18. Have you ever had any broken or fractured bones or dislocated joints? YesNo
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, cast, or crutches? YesNo
20. Have you ever had a stress fracture? YesNo
21. Do you regularly use a brace, orthotics, or other assistive device? YesNo
22. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) YesNo
23. Do you have a bone, muscle, or joint injury that bothers you? YesNo
24. Do any of your joints become painful, swollen, feel warm, or look red? YesNo
25. Do you have any history of juvenile arthritis or connective tissue disease? YesNo

Medical Questions

26. Do you cough, wheeze, or have difficulty breathing during or after exercise? YesNo
27. Have you ever used an inhaler or taken asthma medicine? YesNo
28. Is there anyone in your family who has asthma? YesNo
29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? YesNo
30. Do you have groin pain or a painful bulge or hernia in the groin area? YesNo
31. Have you had infectious mononucleosis (mono) in the last month? YesNo
32. Do you have any rashes, pressure sores, or other skin problems? YesNo
33. Have you had a herpes or MRSA skin infection? YesNo
34. Do you have a history of seizure disorder? YesNo
35. Do you have headaches with exercise? YesNo
36. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? YesNo
37. Have you ever been unable to move your arms or legs after being hit or falling? YesNo
38. Have you ever become ill while exercising in the heat? YesNo
39. Do you get frequent muscle cramps when exercising? YesNo
40. Do you or someone in your family have sickle cell trait or disease? YesNo
41. Have you had any problems with your eyes or vision? YesNo
42. Have you had any eye injuries? YesNo
43. Do you wear glasses or contact lenses? YesNo
44. Do you wear protective eyewear, such as goggles or a face shield? YesNo
45. Do you worry about your weight? YesNo
46. Are you trying or has anyone recommended that you gain or lose weight? YesNo
47. Are you on a special Diet or do you avoid certain types of foods? YesNo
48. Have you ever had an eating disorder? YesNo
49. Do you have any concerns that you would like to discuss with a doctor? YesNo

Females Only

50. Have you ever had a menstrual period? YesNo
51. How old were you when you had your first menstrual period?
52. How many periods have you had in the past 12 months?

I hereby state that, to best of my knowledge, my answers to the above questions are complete and correct.

Athlete’s Signature:

Parent/Guardian Signature:

Date: