ALABAMAHIGHSCHOOLATHLETICASSOCIATION

PreparticipationPhysicalEvaluation Form

HistoryDate_______________________

Name__________________________________________________Sex________ Age______ Dateof birth_______________

Address______________________________________________________________________ Phone______________________
School________________________________________________________Grade__________Sport______________________
ExplainYesanswersbelow:

1. Hasadoctoreverrestricted/deniedyourparticipationinsports?
2. Haveyoueverbeenhospitalizedorspentanightinahospital?
Haveeverhadsurgery?
3. Doyouhaveanyongoingmedicalconditions(likeDiabetesorAsthma)?
4. Areyoupresentlytakinganymedicationsorpills(prescriptionoroverthecounter?
5. Doyouhaveanyallergies(medicine,pollens,foods,beesorotherstinginginsects)?
6. Haveyoueverpassedoutduringorafterexercise?
Haveyoueverbeendizzyduringorafterexercise?
Haveyoueverhadchestpainordiscomfortinyourchestduringorafterexercise?
Doyoutiremorequicklythanyourfriendsduringexercise?
Haveyoueverhadhighbloodpressure?
Haveyoueverbeentoldthatyouhaveaheartmurmur,highcholesterol,orheartinfection?
Haveyoueverhadracingofyourheartorskippedheartbeats?
Hasanyoneinyourfamilydiedofheartproblemsorasuddendeathbeforeage50?
Doesanyoneinyourfamilyhaveaheartcondition?
Hasadoctoreverorderedatestonyourheart(EKG,echocardiogram)?
7. Doyouhaveanyskinproblems(itching,rashes,staph,MRSA,acne)?
8. Haveyoueverhadaheadinjuryorconcussion?
Haveyoueverbeenknockedoutorunconscious?
Haveyoueverhadaseizure?
Haveyoueverhadastinger,burner,pinchednerve,orlossoffeelingorweaknessinyourarmsorlegs?
9. Haveyoueverhadheatormusclecramps?
Haveyoueverbeendizzyorpassedoutintheheat?
10. Doyouhavetroublebreathingordoyoucoughduringorafteractivity?
Doyoutakeanymedicationsforasthma(forinstance,inhalers)?
11. Doyouuseanyspecialequipment(pads,braces,neckrolls,mouthguard,eyeguards,etc.)?
12. Haveyouhadanyproblemswithyoureyesorvision?
Doyouwearglassesorcontactsorprotectiveeyewear?
13. Haveyouhadanyothermedicalproblems(infectiousmononucleosis,diabetes,infectiousdiseases,etc.)?
14. Haveyouhadamedicalproblemorinjurysinceyourlastevaluation?
15. Haveyoueverbeentoldyouhavesicklecelltrait?
Hasanyoneinyourfamilyhadsicklecelldiseaseorsicklecelltrait?
16. Haveyoueversprained/strained,dislocated,fractured,brokenorhadrepeatedswellingorother
injuriesofanybonesorjoints?
HeadBackShoulderForearmHandHipKneeAnkle
NeckChestElbowWristFingerThighShinFoot
17. Whenwasyourfirstmenstrualperiod?__________________________________________________________________
Whenwasyourlastmenstrualperiod?___________________________________________________________________
Whatwasthelongesttimebetweenyourperiodslastyear?________________________________________________

Yes

No

ExplainYesanswers:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Iherebystatethat,tothebestofmyknowledge,myanswerstotheabovequestionsarecorrect.

Signatureofathlete___________________________________________________________Date___________________
Signatureofparent/guardian__________________________________________________ DUPLICATEASNEEDED

Rev. 2010FORM5

Page 1 of 2

Preparticipation Physical Evaluation

Physical Examination

Rule1,Sec.14 Inorderforastudenttobeeligibleforinterscholasticathletics,theremustbe
onfileintheSuperintendentsorPrincipalsofficeacurrentphysiciansstatementcertifyingthat
thestudenthaspassedaphysicalexam,andthatintheopinionoftheexaminingphysician(M.D.
orD.O.)thestudentisfullyabletoparticipateininterscholasticathletics(Grade s712).The
AHSAAPhysiciansCertificate(Form5)mustbeused. Aphysicalexamwillsatisfythe
requirementforonecalendaryearfromthedateoftheexam.

Height ____________ Weight _____________ BP _____ / _____ Pulse ____________

Vision R 20 / ____ L 20 / ____ Corrected: Y
LIMITED

Normal

Abnormal Findings

Cardiovascular
Pulses
Heart
Lungs
Skin

COMPLETE

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.