ALABAMAHIGHSCHOOLATHLETICASSOCIATION

Pre-participation PhysicalEvaluation Form

HistoryDate

NameSex Age

Dateof birth

Address Phone

School Grade Sport

Explain“Yes”answers below:YesNo

1.Hasa doctor everrestricted/deniedyour participationin sports?

2.Haveyoueverbeenhospitalizedorspent a night in a hospital?

Haveeverhadsurgery?

3.Do you haveanyongoingmedical conditions(likeDiabetesorAsthma)?

4.Areyou presentlytaking any medicationsorpills(prescription orover‐the‐counter?

5.Do you haveanyallergies (medicine,pollens, foods,beesorotherstinging insects)?

6.Haveyoueverpassed outduringorafterexercise?

Haveyoueverbeendizzy duringorafterexercise?

Haveyoueverhad chestpain ordiscomfortin your chestduring orafterexercise? Do you tiremorequickly than your friendsduringexercise?

Haveyoueverhad highblood pressure?

Haveyoueverbeentoldthat you havea heartmurmur,high cholesterol,orheartinfection? Haveyoueverhad racing ofyour heartorskipped heartbeats?

Hasanyone in your familydied of heartproblems ora suddendeathbefore age50?

Does anyone in your familyhaveaheartcondition?

Hasa doctoreverordereda teston your heart(EKG,echocardiogram)?

7.Do you haveanyskinproblems(itching, rashes,staph, MRSA,acne)?

8.Haveyoueverhada headinjuryorconcussion?

Haveyoueverbeenknockedout orunconscious? Haveyoueverhad aseizure?

Haveyoueverhad astinger,burner,pinched nerve,orlossof feelingorweaknessin your armsorlegs?

9.Haveyoueverhadheatormuscle cramps?

Haveyoueverbeendizzy orpassed out in theheat?

10. Do you havetroublebreathingordo you cough during orafteractivity?

Do you takeany medicationsfor asthma (forinstance, inhalers)?

11. Do you useany specialequipment(pads, braces,neckrolls, mouth guard,eyeguards,etc.)?

12. Haveyouhad any problemswith your eyesorvision?

Do you wearglassesorcontactsorprotectiveeyewear?

13. Haveyouhad any othermedicalproblems(infectious mononucleosis, diabetes,infectious diseases, etc.)?

14. Haveyouhad amedical problem orinjurysince your last evaluation?

15. Haveyoueverbeentoldyou have sickle celltrait?

Hasanyone in your familyhad sicklecelldisease orsicklecelltrait?

16. Haveyoueversprained/strained,dislocated, fractured,brokenorhad repeatedswellingorother injuriesofany bonesorjoints?

HeadBackShoulderForearmHandHipKneeAnkle

NeckChestElbowWristFingerThighShinFoot

17. Whenwasyourfirst menstrual period?When wasyour last menstrual period? What wasthelongesttimebetween your periodslast year?

Explain“Yes”answers:

I herebystatethat,to thebest ofmyknowledge,myanswersto the above questions arecorrect.

Signatureof athlete Date

Signatureof parent/guardian

DUPLICATEAS NEEDED

Rev.2010FORM5Page1of2

Pre-participationPhysicalEvaluation

PhysicalExamination

Rule1,Sec.14— Inorderforastudenttobeeligibleforinterscholasticathletics,theremustbe onfileintheSuperintendent’sorPrincipal’sofficeacurrentphysician’sstatementcertifyingthat thestudenthaspassedaphysicalexam,andthatintheopinionoftheexaminingphysician(M.D. orD.O.)thestudentisfullyableto participateininterscholasticathletics(Grade s 7‐12).The AHSAAPhysiciansCertificate(Form5)mustbeused.Aphysicalexamwillsatisfythe requirementforonecalendaryearfromthedateoftheexam.

LIMITED / Height Weight BP / Pulse Vision R 20 / L 20 / Corrected: YN
Normal / AbnormalFindings
Cardiovascular
Pulses
Heart
Lungs
Skin
E.N.T.
Abdominal
Genitalia (males)
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
Other

Clearance:

A. Cleared

B. Cleared after completing evaluation/rehabilitation for: C. Not cleared for: Collision

Contact

Noncontact Strenuous Moderately strenuous Nonstrenuous

Due to:

Recommendation:

Name of physician Date

Address Phone

.

Signature of physician , M.D. or D.O.