School Sports Pre-Participation Examination – Part 1: Student or Parent Completes
Revised May 2010
NAME: BIRTHDATE://
ADDRESS:PHONE:()
AthleteandParent/Guardian:Pleasereviewallquestionsandanswerthemtothebestofyourability. Explain any YES answers on back.
Medical Provider:Pleasereviewwiththeathletedetailsofanypositiveanswers.
YESNODon’tKnow
1. Hasanyoneintheathlete’sfamilydiedsuddenlybeforetheageof50years?
2. Hastheathleteeverpassedoutduringexerciseorstoppedexercisingbecauseofdizzinessorchestpain?
3. Doestheathletehaveasthma(wheezing),hayfever,otherallergies, or carry an EPI pen?
4. Istheathleteallergictoanymedicationsorbeestings?
5. Hastheathleteeverbrokenabone,hadtowearacast,orhadaninjurytoanyjoint?
6. Hastheathleteeverhadaheadinjuryorconcussion?
7. Hastheathleteeverhadahitorblowtotheheadthatcausedconfusion, memory problems, or prolongedheadache?
8. Hastheathleteeversufferedaheat-relatedillness(heatstroke)?
9. Doestheathletehaveachronicillnessorseeaphysicianregularlyforanyparticularproblem?
10. Doestheathletetakeanyprescribedmedicine,herbsornutritionalsupplements?
11. Doestheathletehaveonlyoneofanypairedorgan(eyes,kidneys,testicles,ovaries,etc.)?
12. Hastheathleteeverhadpriorlimitationfromsportsparticipation?
13. Hastheathletehadanyepisodesofshortnessofbreath,palpitations,historyofrheumaticfeverortiringeasily?
14. Hastheathleteeverbeendiagnosedwithaheartmurmurorheartconditionorhypertension?
15. Isthereahistoryofyoungpeopleintheathlete'sfamilywhohavehadcongenitalorotherheartdisease:
cardiomyopathy,abnormalheartrhythms,longQTorMarfan'ssyndrome? (Youmaywrite"Idon'tunderstandtheseterms"
andinitialthisitem,ifappropriate.)
16. Hastheathleteeverbeenhospitalizedovernightorhadsurgery?
17. Doestheathleteloseweightregularlytomeettherequirementsforyoursport?
18. Doestheathletehaveanythingheorshewantstodiscusswiththephysician?
19. Doestheathletecough,wheeze,orhavetroublebreathingduringorafteractivity?
20. Areyou unhappywithyourweight?
21. FEMALESONLY
a.Whenwasyourfirstmenstrualperiod?
b.Whenwasyourmostrecentmenstrualperiod?
c.Whatwasthelongesttimebetweenmenstrualperiodsinthelastyear?
Parent/Guardian’sStatement:
Ihavereviewedandansweredthequestionsabovetothebestofmyability. Iandmychildunderstandandacceptthattherearerisksofseriousinjuryanddeathinanysport,including theone(s)inwhichmychildhaschosentoparticipate. Iherebygivepermissionformychildtoparticipateinsports/activities.
Iherebyauthorizeemergencymedicaltreatmentand/ortransportationtoamedicalfacilityforanyinjuryorillnessdeemedurgentlynecessarybya registeredathletictrainer,coach,or medicalpractitioner.
Iunderstandthatthissportspre-participationphysicalexaminationisnotdesignednorintendedtosubstituteforanyrecommendedregularcomprehensivehealthassessment.
Iherebyauthorizereleaseoftheseexaminationresultstomychild'sschool.
Signed: Date:
Parent/Guardian
ORS336.479,Section1(3)"Aschooldistrictshallrequirestudentswhocontinuetoparticipateinextracurricularsportsingrades7through12tohaveaphysicalexaminationonce everytwoyears." Section1(5)“Anyphysicalexaminationrequiredbythissectionshallbeconductedbya(a)physicianpossessinganunrestrictedlicensetopracticemedicine;(b)licensednaturopathicphysician;(c)licensedphysicianassistant;(d)certifiednursepractitioner;ora(e)licensedchiropracticphysicianwhohasclinicaltrainingandexperienceindetecting cardiopulmonarydiseasesanddefects.”
Revised May 2010
SchoolSportsPre-ParticipationExamination – Part 2 Medical Provider Completes
NAME:BIRTHDATE://
Height:Weight:
%BodyFat(optional):
Pulse:BP:
____/____ (____/____,____/____)
Vision: R20/_____ L20/_____Corrected:Y NPupils: Equal_____ Unequal_____
Rhythm: Regular_____Irregular_____
MEDICAL / NORMAL / ABNORMALFINDINGS / INITIALS*Appearance
Eyes/Ears/Nose/Throat
LymphNodes
Heart:Pericardialactivity
1st2ndheartsounds
Murmurs
Pulses:brachial/femoral
Lungs
Abdomen
Skin
MUSCULOSKELETAL
*Station-basedexaminationonly
Cleared
Clearedaftercompletingevaluation/rehabilitationfor: Notclearedfor:
Recommendations:
CLEARANCE
Reason:
Nameof Medical Provider(print/type):
Date://
Address:Phone: ()
Signatureof Medical Provider:
AsperORS336.479,Section1(3)"Aschooldistrictshallrequirestudentswhocontinuetoparticipateinextracurricularsportsingrades7through12tohaveaphysicalexaminationonce everytwoyears." Section1(5)“Anyphysicalexaminationrequiredbythissectionshallbeconductedbya(a)physicianpossessinganunrestrictedlicensetopracticemedicine;(b)licensednaturopathicphysician;(c)licensedphysicianassistant;(d)certifiednursepractitioner;ora(e)licensedchiropracticphysicianwhohasclinicaltrainingandexperienceindetecting cardiopulmonarydiseasesanddefects.”
Revised May 2010
SUGGESTED EXAMPROTOCOL FOR THE PHYSICIAN
MUSCULOSKELETAL
Havepatient:Tocheckfor:
1.StandfacingexaminerACjoints,generalhabitus
2.Lookatceiling,floor,overshoulders,touchearstoshouldersCervicalspinemotion
3.Shrugshoulders(againstresistance)Trapeziusstrength
4.Abductshoulders90degrees,holdagainstresistanceDeltoidstrength
5.ExternallyrotatearmsfullyShouldermotion
6.FlexandextendelbowsElbowmotion
7.Armsatsides,elbows90degreesflexed,pronate/supinatewristsElbowandwristmotion
8.Spreadfingers,makefistHandandfingermotion,deformities
9.Contractquadriceps,relaxquadricepsSymmetryandknee/ankleeffusion
10.“Duckwalk”4stepsawayfromexaminerHip,kneeandanklemotion
11.StandwithbacktoexaminerShouldersymmetry,scoliosis
12.Kneesstraight,touchtoesScoliosis,hipmotion,hamstrings
13.Riseuponheels,thentoesCalfsymmetry,legstrength
MURMUR EVALUATION – Auscultation should be performed sitting, supine and squaring in a quiet room using the diaphragm and bell of a stethoscope.
Auscultationfindingof:Rulesout:
1.S1heardeasily;notholosystolic,soft,low-pitchedVSDandmitralregurgitation
2.NormalS2Tetralogy,ASDandpulmonaryhypertension
3.Noejectionormid-systolicclickAorticstenosisandpulmonarystenosis
4.ContinuousdiastolicmurmurabsentPatentductusarteriosus
5.NoearlydiastolicmurmurAorticinsufficiency
6.NormalfemoralpulsesCoarctation
(Equivalenttobrachialpulsesinstrengthandarrival)
MARFAN’S SCREEN – Screen all men over 6’0” and all women over 5’10” in height with echocardiogram and slit lamp exam when any two of the following are found:
1.FamilyhistoryofMarfan’ssyndrome(thisfindingaloneshouldpromptfurtherinvestigation)
2.Cardiacmurmurormid-systolicclick
3.Kyphoscoliosis
4.Anteriorthoracicdeformity
5.Armspangreaterthanheight
6.Uppertolowerbodyratiomorethan1standard deviationbelowmean
7.Myopia
8.Ectopiclens
CONCUSSION -- When can an athlete return to play after a concussion?
After suffering a concussion, no athlete should return to play or practice on the same day. Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown that the young brain does not recover that quickly, thus the Oregon Legislature has established a rule that no player shall return to play following a concussion on that same day and the athlete must be cleared by an appropriate health care professional before they are allowed to return to play or practice.
Once an athlete is cleared to return to play they should proceed with activity in a stepwise fashion to allow their brain to readjust to exertion. The athlete may complete a new step each day. The return to play schedule should proceed as below following medical clearance:
Step 1:Lightexercise,includingwalkingorridinganexercisebike. Noweightlifting.
Step 2:Runninginthegymoronthefield. Nohelmetorotherequipment.
Step 3:Non-contacttrainingdrillsinfullequipment. Weighttrainingcanbegin. Step 4:Fullcontactpracticeortraining.
Step 5:Gameplay.
Ifsymptomsoccuratanystep,theathleteshouldceaseactivityandbere-evaluatedbyahealthcareprovider.
Revised May 2010