Athletic Pre-Participation Screening Exam

Part 1: (To be completed by student and parents/guardian)

Name

ID #

_ School

Grade

Address
Age

Sex

Sport(s)

Birthday

Doctors Name

Dr. Phone (

Health Insurance

/
_

Policy Number

HEALTH HISTORY (must be completed prior to exam)

Has student had any:

Hospitalization?
Surgery other than remove of
tonsils?
Missing organs (eye, kidney,
testicle)?
Allergies (medicines, insects,
food)?
Exertional chest pain/discomfort?
Excessive exertional and
unexplained shortness of
breath/fatigue with exercise?
High blood pressure?
Heart murmur noted?
Unexplained loss of consciousness
or near loss of consciousness?
Heat exhaustion, heat stroke or
other problems with heat?
Mono, hepatitis, hemophilia?
Diabetes?
Seizures/convulsion?
Family member with
cardiomyopathy, Marfan's
Long QT or clinically important
heart beat abnormality (arrhythmia)

Date of last known Tetanus shot

Is there any history of:

Neck or back injury?
Knee injury?
Shoulder or elbow injury?
Ankle injury?
Dislocation of a joint?
Catching or locking joint?
Broken bones / fractures?
Ulcers or hernias?
Stingers / burners?
Skin problems?

Further history:
Has any family member
died suddenly at less than
50 years of age of causes
other than an accident?
Has any family member
been disabled by heart
disease less than 50
years of age?

USE THIS SPACE TO EXPLAIN ANY YES ANSWERS TO THE ABOVE QUESTIONS

Parents / Guardians Acknowledgement:

I have reviewed and agree with the information presented on this form. I also understand that this examination is primarily for
sports participation screening and is not intended to replace routine health care visits as recommended by the students
personal physician. I know of no reason why the above named student should not participate and represent his or her school
supervised athletic activities.
Print name of parent/guardian

Signature of parent/guardian
_

Home Phone

Work Phone

Email

Date

Part 2:General Exam (To be completed by examining physician)

Normal
Eyes, Ears, Nose, Throat
Skin
Lungs
Heart
Murmur
Femoral Pulses
Abdomen
Genitalia/Hernia(males)

Abnormal (Describe)
Pulse:
BP:
Height:
Weight:

(No)

Yes:
Weaker than brachial?

Suggested Musculoskeletal Exam

S
P
I
N
E

ROM/STRENGTH
CERVICAL
Flex/Ext
Rotation Right/Left
Lateral flexion Right/Left
THORATIC LUMBAR
Flex/Ext
Rotation Right/Left
Lateral flexion Right/Left
Abdominals/Obliques

NL

U
P
R

SHOULDER
Forward flexion/ext
Abduction/Adduction
Internal/Ext rotation
E Horizontal Abd/Add
X A-C joint/clavicle
T Stability testing
R
ELBOW
Supination/Pronation
M
Wrist/Hand
Y

GENERAL FLEXIBILITY
Hamstrings
Marfan's? Quadriceps
height Lumbar Spine
Achilles

AB

ROM/STRENGTH
HIP
Hip flexor/Gluteals
Add/Abd-Groin/IT
L Int./Ext rotation
O
KNEE
W Patellar Tendon
E Tibial Tuberosity
R MCL/LCL
ACL/PCL
E Cartilage testing
X Quads/Hamstrings
T Gast/soleus complex
PATELLA
R
E Crepitus
M Tracking
ANKLE
I
T Plantar/Dorsiflexion
Y Inversion/Eversion
Subtalar joint
Ligament testing
Fe
et/
To
es

NL

AB

Describe Abnormal

Findings of
Arm span >
Hyperflexibility

Disposition:
o Cleared for collision, contact and non-contact sport.
o Conditional participation, limited to
o No participation until
o No participation in any sport or physical education because of

DOCTOR SIGNATURE

MD LICENSE #

DATE