History and Physical Examination

All performers must have a physical exam form on file PRIOR TO PARTICIPATION. A
physical examination must be completed annually. If you have had a physical
examination within the last 6 months a copy of the most recent Examination form
may be completed and accepted. Otherwise, you need to complete a Physical
Examination.

INSTRUCTIONS:

HISTORY FORM and PHYSICAL EXAMINATION FORM

 Complete the HISTORY FORM information prior to your examination.

Give the completed form to your physician/provider at the time of
your examination.
 The PHYSICAL EXAMINATION FORM is to be completed by the
physician/provider.
 The HISTORY and PHYSICAL EXAMINATION FORMS are to be reviewed and
completed by the physician/provider.
 Completed Examination form or recent Examination form, and health
history form must be returned.
Physical Evaluation (Medical History form is to be reviewed by HISTORY FORM
Physician/Provider)

DATE OF EXAM:__________________________________

Name (Last)__________________________________ (First)________________________ (Middle Initial)________ Date

of Birth______________
Age__________ Sex__________ Sport(s)_________________________________ Address
____________________________________________
City_______________________________________ State__________ Zip
Code______________Telephone_______________________________
Personal
Physician__________________________________________________________________________________________________
_____
Explain “Yes” answer(s) below. Circle questions you don’t know the answers to.
Yes Yes
No No
1. Has a doctor ever denied or restricted your
participation in sports for any reason? 26. Have you ever used an inhaler or taken
asthma medicine?
2. Do you have an ongoing medical 27. Were you born without or are you missing a
condition? (like diabetes or asthma)? kidney, an eye,
a testicle or any other organ?
3. Are you currently taking any prescription 28. Have you had infectious mononucleosis
or nonprescription (over-the-counter) (mono) within
medicines or pills? the last month?
4. Do you have allergies to medicines,
pollens, foods, or stinging insects? 29. Do you have rashes, pressure sores, or
other skin problems?
5. Have you ever passed out or nearly passed
out DURING exercise? 30. Have you had a herpes skin infection?
6. Have you ever passed out or nearly passed
out AFTER exercise? 31. Have you ever had a head injury or
concussion?
7. Have you ever had discomfort, pain, or 32. Have you been hit in the head and been
pressure in your chest during exercise? confused or lost your memory?
8. Does your heart race or skip beats during 33. Have you ever had a seizure?
exercise?
9. Has a doctor ever told you that you have
(check all that apply): High blood 34. Do you have headaches with exercise?
pressure A heart murmur
High cholesterol A
heart infection
10. Has a doctor ever ordered a test for your 35. Have you ever had numbness, tingling, or
heart? (for example, ECG, echocardiogram) weak-
ness in your arms or legs after being hit or
falling?
11. Has anyone in your family died for no 36. Have you ever been unable to move your
apparent reason? arms or legs
after being hit or falling?
12. Does anyone in your family have a heart 37. When exercising in the heat, do you have
problem? severe muscle
cramps or become ill?
13. Has any family member or relative died of 38. Has a doctor told you that you or someone
heart problems or of sudden death before in your
age 50? family has sickle cell trait or sickle cell
disease?
14. Does anyone in your family have Marfan 39. Have you had any problems with your eyes
syndrome? or vision?
15. Have you ever spent the night in a 40. Do you wear glasses or contact lenses?
hospital?
16. Have you ever had surgery? 41. Do you wear protective eyewear, such as
goggles or a
face shield?
17. Have you ever had an injury, like a sprain, 42. Are you happy with your weight?
muscle or
43. Are you trying to gain or lose weight?
 ligament tear, or tendonitis, that caused
you to miss a
practice or game? If yes, circle affected
area below:
18. Have you had any broken or fractured 44. Has anyone recommended you change your
bones or dislocated weight or eating habits?
joints? If yes, circle below.
19. Have you had a bone or joint injury that 45. Do you limit or carefully control what you
required x-rays, MRI, eat?
CT, surgery, injections, rehabilitation, 46. Do you have any concerns that you would
physical therapy, a like to discuss with
brace, a cast, or crutches? If yes, circle a doctor?
below:
Hea Neck Shou Upp Elbo Fore Han Ches
d l-der er w -arm d/ t 47. Do you have any concerns you would like to
arm finge discuss with the doctor?
rs
Upp Low Hip Thig Knee Calf/ Ankl Foot/
er er h Shin e Toes
Back Back
Explain “Yes” answers
20. Have you ever had a stress fracture? here:_______________________________
_________________________________________________
_____
21. Have you been told that you have or have _________________________________________________
you had an x-ray _____
for atlantoaxial (neck) instability? _________________________________________________
_____
22. Do you regularly use a brace or assistive _________________________________________________
device? _____
23. Has a doctor ever told you that you have _________________________________________________
asthma or allergies? _____
24. Do you cough, wheeze, or have difficulty
breathing during or
after exercise?
25. Is there anyone in your family who has
asthma?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and accurate.

Name (Please Print) _______________________________ Signature of

parent/guardian_________________________________ Date__________
PHYSICAL EXAMINATION FORM
Physical Evaluation
(Medical History and Physician Examination forms
are to be
completed by Physician/Provider)

Name (Last)__________________________________ (First)________________________ (Middle Initial)________ Date

of Birth______________

Height__________ Weight__________ %Body fat (optional)__________ Pulse_________ BP_____ / _____

(_____ / _____ , _____ / _____ )

Vision R20 / _______ L20 / _______ Corrected: Y N PUPILS: EQUAL__________

UNEQUAL__________ YES NO

NORMAL ABNORMAL FINDINGS INITIALS*

MEDICAL
Appearance
Eyes/Ears/Nose/Throat
Hearing
Lymph Nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitalia/Hernia

MUSCULOSKELETAL
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
*Multiple-examiner set-up only.

Notes:_____________________________________________________________________________________________________
____________

___________________________________________________________________________________________________________
___________

Name of Physician (print/type)_____________________________________________________________

Date:____________________

Address_________________________________________________________________________________
Telephone:____________________

Signature of Physician:_________________________________________________MD/DO or
APNP:___________________________________
 Physician/Provider

ATHLETIC PHYSICAL EXAM PERMIT

NAME
Last First Middle Initial Date of Birth

Age Sex

Present Address Phone

Cleared without restriction

Recommendation for next Physical Examination: ________________________

(Month/Year)

Cleared, with recommendation for further evaluation or treatment for:

Not cleared for All sports Certain sports:

Reason:

Recommendations:

SIGNATURE OF LICENSED PHYSICIAN *

Address City State Zip Code

Phone Date of Examination

*Physicians may authorize Nurse Practitioners or Physician Assistants to stamp this form with the
physician’s signature or the name of the clinic with which the physician is affiliated.