OREGON SCHOOL ACTIVITIES ASSOCIATION SCHOOL SPORTS PRE-PARTICIPATION EXAMINATION NAME: ____________________________________ BIRTHDATE: ___/___/___ ADDRESS: ____________________________________ PHONE: __________________________ Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability. Physician: Please review with the athlete details of any positive answers. YES NO Don't Know ___ ___ ____ 1. Has anyone in the athlete's family died suddenly before the age of 50 years? ___ ___ ____ 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain? ___ ___ ____ 3. Does the athlete have asthma (wheezing), hay fever, or coughing spells during or after exercise? ___ ___ ____ 4. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint? ___ ___ ____ 5. Does the athlete have a history of a concussion (getting knocked out) or seizures? ___ ___ ____ 6. Has the athlete ever suffered a heat-related illness (heat stroke)? ___ ___ ____ 7. Does the athlete have a chronic illness or see a physician regularly for any particular problem? ___ ___ ____ 8. Does the athlete take any medicine? ___ ___ ____ 9. Is the athlete allergic to any medications or bee stings? ___ ___ ____ 10. Does the athlete have only one of any paired organ (eyes, ears, kidneys, testicles, ovaries, etc.)? ___ ___ ____ 11. Has the athlete ever had prior limitation from sports participation? ___ ___ ____ 12. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or unusual fatigability? ___ ___ ____ 13. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension? ___ ___ ____ 14. Is there a history of young people in the athlete's family who have had congenital or other heart disease: cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome? (You may write "I don't understand these terms" and initial this item, if appropriate.) ___ ___ ____ 15. Has the athlete ever been hospitalized overnight or had surgery? ___ ___ ____ 16. Does the athlete lose weight regularly to meet the requirements for your sport? ___ ___ ____ 17. Does the athlete have anything he or she wants to discuss with the physician? Explain any YES answers here: ____________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Parent/Guardian's Statement: I have reviewed and answered the questions above to the best of my ability. I and my child understand and accept that there are risks of serious injury and death in any sport, including the one(s) in which my child has chosen to participate. I hereby give permission for my child to participate in sports. I hereby authorize emergency medical treatment and/or transportation to a medical facility for any injury or illness deemed urgently necessary by a licensed trainer, coach, or medical practitioner. I understand that this sports pre-participation physical examination is not designed nor intended to substitute for any recommended regular comprehensive health assessment by the family's licensed medical practitioner, nor to discover hidden or unknown illness or injury reasonably outside the realm of sports participation. Signed: ____________________________________________ Date: __________________ Parent/Guardian: ______________________________________ F:\Data\Forms\00-01\Pre-Participation Exam.doc Effective: 09/00 PRE-PARTICIPATION PHYSICAL EXAMINATION Name _______________________________________________________________________ Date of Birth ____/____/_____ Height _______ Weight _______ % Body fat (optional) _______ Pulse _______ BP _____/_____ ( _____/_____ , _____/_____ ) Rhythm: Regular ____ Irregular ____ Vision R 20 / ____ L 20 / ____ Corrected: Y N Pupils: Equal ____ Unequal ____ NORMAL ABNORMAL FINDINGS INITIALS* MEDICAL Appearance _________ _________________________________________ _________ Eyes/Ears/Nose/Throat _________ _________________________________________ _________ Lymph Nodes _________ _________________________________________ _________ Heart: Precordial activity _________ _________________________________________ _________ 1st & 2nd heart sounds _________ _________________________________________ _________ Murmurs _________ _________________________________________ _________ Pulses: brachial/femoral _________ _________________________________________ _________ Lungs _________ _________________________________________ _________ Abdomen _________ _________________________________________ _________ Skin _________ _________________________________________ _________ MUSCULOSKELETAL Neck _________ _________________________________________ _________ Back _________ _________________________________________ _________ Shoulder/arm _________ _________________________________________ _________ Elbow/forearm _________ _________________________________________ _________ Wrist/hand _________ _________________________________________ _________ Hip/thigh _________ _________________________________________ _________ Knee _________ _________________________________________ _________ Leg/ankle _________ _________________________________________ _________ Foot _________ _________________________________________ _________ * Station-based examination only CLEARANCE Cleared _________ Cleared after completing evaluation/rehabilitation for: _______________________________________ Not cleared for: Reason: ____________________________________________________________________ Recommendations: _________________________________________________________________________ Name of physician (print/type): _________________________________________ Date: ____ / ____ / ____ Address: Phone (_____) ___________ Signature of Physician: _________________________________________ F:\Data\Forms\00-01\Pre-Participation Exam.doc Effective: 09/00 SUGGESTED EXAM PROTOCOL FOR THE PHYSICIAN MUSCULOSKELETAL Have patient: To check for: 1. Stand facing examiner AC joints, general habitus 2. Look at ceiling, floor, over shoulders, touch ears to shoulders Cervical spine motion 3. Shrug shoulders (against resistance) Trapezius strength 4. Abduct shoulders 90 degrees, hold against resistance Deltoid strength 5. Externally rotate arms fully Shoulder motion 6. Flex and extend elbows Elbow motion 7. Arms at sides, elbows 90 degrees flexed, pronate / supinate wrists Elbow and wrist motion 8. Spread fingers, make fist Hand and finger motion, deformities 9. Contract quadriceps, relax quadriceps Symmetry and knee/ankle effusion 10. "Duck walk" 4 steps away from examiner Hip, knee and ankle motion 11. Stand with back to examiner Shoulder symmetry, scoliosis 12. Knees straight, touch toes Scoliosis, hip motion, hamstrings 13. Rise up on heels, then toes Calf symmetry, leg strength MURMUR EVALUATION - Auscultation should be performed sitting, supine and squatting in a quiet room using the diaphragm and bell of a stethoscope. Auscultation finding of: Rules out: 1. S1 heard easily; not holosystolic, soft, low-pitched VSD and mitral regurgitation 2. Normal S2 Tetralogy, ASD and pulmonary hypertension 3. No ejection or mid-systolic click Aortic stenosis and pulmonary stenosis 4. Continuous diastolic murmur absent Patent ductus arteriosus 5. No early diastolic murmur Aortic insufficiency 6. Normal femoral pulses Coarctation (Equivalent to brachial pulses in strength and arrival) MARFAN'S SCREEN - Screen all men over 6'0" and all women over 5'10" in height with EKG and slit lamp exam when any two of the following are found: 1. Family history of Marfan's syndrome (this finding alone should prompt further investigation) 2. Cardiac murmur or mid-systolic click 3. Kyphoscoliosis 4. Anterior thoracic deformity 5. Arm span greater than height 6. Upper to lower body ratio more than 1 SD below mean 7. Myopia 8. Ectopic lens F:\Data\Forms\00-01\Pre-Participation Exam.doc Effective: 09/00 |
