PREPARTICIPATION PHYSICALEVALUATION | Ohio High School Athletic Association – 2021-2022

HISTORY FORM

Note: Complete and sign this form (with your parents if younger than 18) before your appointment. Name:_____________________________________________________ Date of birth: ______________ Grade in School: _______________

Date of examination: 	

Sex assigned at birth (F, M, or intersex): 	

Sport(s):	

How do you identify your gender? (F, M, or other): 	

List past and current medical conditions:	

Have you ever had surgery? If yes, list all past surgical procedures:	

Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional):	

Do you have any allergies? If yes, please list all your allergies (i.e., medicines, pollens, food, stinging insects):

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

Not at all 0 0 0
0

Several days 1 1 1
1

Over half the days 2 2 2
2

Nearly every day 3 3 3
3

(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

GENERAL QUESTIONS
(Explain “Yes” answers at the end of this form.
Circle questions if you don’t know the answer.)

Yes

No
	
1. Do you have any concerns that you would like to discuss with your provider?
			
2. Has a provider ever denied or restricted your participation in sports for any reason?
			
3. Do you have any ongoing medical issues or recent illness?
			
HEART HEALTH QUESTIONS ABOUT YOU
	Yes
	No
	
4. Have you ever passed out or nearly passed out during or after exercise?
			
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
			
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
			
7. Has a doctor ever told you that you have any heart problems?
			
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.

HEART HEALTH QUESTIONS ABOUT YOU
(CONTINUED )
	
Yes
	
No
	
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
			
10. Have you ever had a seizure?
			
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
	Yes
	No
	
11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?
			
12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly-morphic ventricular tachycardia (CPVT)?
			
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

COVID-19 QUESTIONS ABOUT YOU
	Yes
	No
	
14. Have you had COVID-19 or tested positive for COVID-19?
			
15. If answered yes, when did you have/test positive for COVID-19?
		
16. If answered yes, have you had any ongoing medical issues secondary to COVID-19?
			
17. If answered yes, were you cleared by a health care provider following the diagnosis to return to sport activity?
			
18. Has a physician ever denied or restricted your participation in sports for reasons related to COVID-19?
			
19. If answered yes, please state reasoning:
		
20. Have you been vaccinated for COVID-19?
			
21. Please list date(s) of vaccine(s), if applicable:
		
BONE & JOINT QUESTIONS
	Yes
	No
	
22. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon thatcaused you to miss a practice or game?
			
23. Do you have a bone, muscle, ligament, or joint injury that bothers you?
			
MEDICAL QUESTIONS
	Yes
	No
	
24. Do you cough, wheeze, or have difficulty breathing during or after exercise?
			
25. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
			
26. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
			
27. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
			
28. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
			
29. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
			
30. Have you ever become ill while exercising in the heat?
			
31. Do you or does someone in your family have sickle cell trait or disease?
			
32. Have you ever had, or do you have any problems with your eyes or vision?

MEDICAL QUESTIONS (CONTINUED )
	Yes
	No
	
33. Do you worry about your weight?
			
34. Are you trying to or has anyone recommended that you gain or lose weight?
			
35. Are you on a special diet or do you avoid certain types of foods or food groups?
			
36. Have you ever had an eating disorder?
			
FEMALES ONLY
	Yes
	No
	
37. Have you ever had a menstrual period?
			
38. How old were you when you had your first menstrual period?
		
39. When was your most recent menstrual period?
		
40. How many periods have you had in the past 12 months?

Explain “Yes” answers here:

…continued next page…

Additional questions, as authorized by the Ohio High School Athletic Association, were not a part of the
revised 5th edition PPE as authored by the American Academy of Pediatrics and are optional.
1. On average, how many days per week do you engage in moderate to strenuous exercise (makes you breathe heavily or sweat)?
2. On average, how many minutes per week do you engage in exercise at this level?

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

Signature of athlete: 	

Signature of parent or guardian: 	

Date: 	

© 2019 American Academyof FamilyPhysicians, American Academy of Pediatrics, American Collegeof SportsMedicine, American MedicalSocietyfor Sports Medicine, American OrthopaedicSocietyfor Sports Medicine,and American Osteopathic Academy of SportsMedicine. Permission isgranted to reprint for noncommercial, educa-tionalpurposes with acknowledgment.

PREPARTICIPATION PHYSICALEVALUATION | Ohio High School Athletic Association – 2021-2022

ATHLETES WITH DISABILITIES FORM: SUPPLEMENT TO THE ATHLETE HISTORY

Name:	Date of birth: 	

1. Type of disability:
	
2. Date of disability:
	
3. Classification (if available):
	
4. Cause of disability (birth, disease, injury, or other):
	
5. List the sports you are playing:
	
	Yes
	No
	
6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?
			
7. Do you use any special brace or assistive device for sports?
			
8. Do you have any rashes, pressure sores, or other skin problems?
			
9. Do you have a hearing loss? Do you use a hearing aid?
			
10. Do you have a visual impairment?
			
11. Do you use any special devices for bowel or bladder function?
			
12. Do you have burning or discomfort when urinating?
			
13. Have you had autonomic dysreflexia?
			
14. Have you ever been diagnosed as having a heat-related (hyperthermia) or cold-related (hypothermia) illness?
			
15. Do you have muscle spasticity?
			
16. Do you have frequent seizures that cannot be controlled by medication?

Explain “Yes” answers here:

Please indicate whether you have ever had any of the following conditions:

	Yes
	No
	
Atlantoaxial instability
			
Radiographic (x-ray) evaluation for atlantoaxial instability
			
Dislocated joints (more than one)
			
Easy bleeding
			
Enlarged spleen
			
Hepatitis
			
Osteopenia or osteoporosis
			
Difficulty controlling bowel
			
Difficulty controlling bladder
			
Numbness or tingling in arms or hands
			
Numbness or tingling in legs or feet
			
Weakness in arms or hands
			
Weakness in legs or feet
			
Recent change in coordination
			
Recent change in ability to walk
			
Spina bifida
			
Latex allergy

Explain “Yes” answers here:

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

Signature of athlete: 	

Signature of parent or guardian: 	

Date: 	

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.

PREPARTICIPATION PHYSICALEVALUATION – Ohio High School Athletic Association – 2021-2022

PHYSICAL EXAMINATION FORM

Name:	Date of Birth:	Grade in School:

PHYSICIAN REMINDERS

1. Consider additional questions on more-sensitive issues. •     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, e-cigarettes, chewing tobacco, snuff, or dip? •     During the past 30 days, did you use 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-enhancing supplement?

•     Have you ever taken any supplements to help you gain or lose weight or improve your performance? •     Do you wear a seat belt, use a helmet, and use condoms?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).

EXAMINATION
	
Height:	Weight:
	
BP:	/	(	/	)	Pulse:	Vision: R 20/	L 20/	Corrected:     □ Y     □ N
	
MEDICAL
	NORMAL
	ABNORMAL FINDINGS
	
Appearance
•     Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve prolapse [MVP], and aortic insufficiency)
			
Eyes, ears, nose, and throat •     Pupils equal
•     Hearing
			
Lymph nodes
			
Hearta
•     Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
			
Lungs
			
Abdomen
			
Skin
•     Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or tinea corporis
			
Neurological
			
MUSCULOSKELETAL
	NORMAL
	ABNORMAL FINDINGS
	
Neck
			
Back
			
Shoulder and arm
			
Elbow and forearm
			
Wrist, hand, and fingers
			
Hip and thigh
			
Knee
			
Leg and ankle
			
Foot and toes
			
Functional
•     Double-leg squat test, single-leg squat test, and box drop or step drop test

a Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-nation of those.
Name of health care professional (print or type):	Date: 	

Address:	Phone: 	

Signature of health care professional: _______________________________________________________________________, MD, DO, DC, NP,or PA

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.

PREPARTICIPATION PHYSICAL EVALUATION | OHIO HIGH SCHOOL ATHLETIC ASSOCIATION – 2021-2022

MEDICAL ELIGIBILITY FORM

Name:	Date of Birth:	Grade in School:

□ Medically eligible for all sports without restriction

□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

□ Medically eligible for certain sports

□ Not medically eligible pending further evaluation

□ Not medically eligible for any sports

Recommendations: 	

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does not have apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the physical examination findings is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional (print or type): 	

Address: 	

Date of Exam:	

Phone: 	

Signature of health care professional: ________________________________________________________________________, MD, DO, DC, NP,or PA

SHARED EMERGENCY INFORMATION

Allergies: 	

Medications: 	

Other information: 	

Emergency contacts: 	

© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educa-tional purposes with acknowledgment.