Ihsa Sports Form Details

All high school athletes in Illinois must complete a pre-participation physical examination before they can begin practicing or competing. The form, which is available on the Illinois Athletic Trainer Association website, must be filled out by a licensed health care provider and includes questions about the athlete's health history, medications, and current injuries. (Link to full blog post below) Completing the Illinois Pre Participation Physical Form is important for helping to ensure that athletes are healthy enough to participate in sports. The form includes questions about the athlete's health history, current medications, and any injuries they may have sustained previously. It's important to fill out the form completely and honestly so that athletes can receive appropriate care if they suffer an injury while playing sports.

If you need to first determine how much time you need to complete the illinois pre participation physical form and what number of pages it has, here

QuestionAnswer
Form NameIllinois Pre Participation Physical Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois sports physical form 2020, illinois sports physical form, illinois sports form, illinois sports physical form 2021

Form Preview Example

Pre-participation Examination

To be completed by athlete or parent prior to examination.

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

School Year

 

 

 

Last

First

Middle

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

City/State

 

Phone No.

 

Birthdate

 

Age

Class

 

 

Student ID No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pare t’s Na e

 

 

 

 

 

 

Phone No.

Address

 

 

 

 

 

 

 

 

City/State

 

 

HISTORY FORM

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking

Do you have any allergies?

Yes

No

If yes, please identify specific allergy below.

 

 

Medicines

 

 

Pollens

Food

Stinging Insects

 

 

 

 

E plain Yes answe s elow. Ci

le uestions ou don’t know the answe s to.

 

 

 

GENERAL QUESTIONS

 

 

 

Yes

No

1.

Has a doctor ever denied or restricted your participation in sports

 

 

 

 

for any reason?

 

 

 

 

 

2.

Do you have any ongoing medical conditions? If so, please identify

 

 

 

 

below: Asthma Anemia Diabetes Infections

 

 

 

 

 

 

 

Other: _

 

__________

 

 

 

 

 

 

 

 

 

 

 

3.

Have you ever spent the night in the hospital?

 

 

 

 

 

4.

Have you ever had surgery?

 

 

 

 

 

 

HEART HEALTH QUESTIONS ABOUT YOU

 

 

 

Yes

No

5.

Have you ever passed out or nearly passed out DURING or AFTER

 

 

 

 

exercise?

 

 

 

 

 

6.

Have you ever had discomfort, pain, tightness, or pressure in your

 

 

 

 

chest during exercise?

 

 

 

 

 

7.

Does your heart ever race or skip beats (irregular beats) during

 

 

 

 

exercise?

 

 

 

 

 

8.

Has a doctor ever told you that you have any heart problems? If

 

 

 

 

so, check all that apply: High blood pressure A heart murmur

 

 

 

 

High cholesterol A heart infection Kawasaki disease

 

 

 

 

Other: ___

 

 

______

 

 

 

 

 

 

 

9.

Has a doctor ever ordered a test for your heart? (For example,

 

 

 

 

ECG/EKG, echocardiogram)

 

 

 

 

 

10.

Do you get lightheaded or feel more short of breath than

 

 

 

 

expected during exercise?

 

 

 

 

 

11.

Have you ever had an unexplained seizure?

 

 

 

 

 

12.

Do you get more tired or short of breath more quickly than your

 

 

 

 

friends during exercise?

 

 

 

 

 

 

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

 

 

 

Yes

No

13.

Has any family member or relative died of heart problems or had

 

 

 

 

an unexpected or unexplained sudden death before age 50

 

 

 

 

(including drowning, unexplained car accident, or sudden infant

 

 

 

 

death syndrome)?

 

 

 

 

 

14.

Does anyone in your family have hypertrophic cardiomyopathy,

 

 

 

 

Marfan syndrome, arrhythmogenic right ventricular

 

 

 

 

 

 

 

cardiomyopathy, long QT syndrome, short QT syndrome, Brugada

 

 

 

 

syndrome, or catecholaminergic polymorphic ventricular

 

 

 

 

tachycardia?

 

 

 

 

 

15.

Does anyone in your family have a heart problem, pacemaker, or

 

 

 

 

implanted defibrillator?

 

 

 

 

 

16.

Has anyone in your family had unexplained fainting, unexplained

 

 

 

 

seizures, or near drowning?

 

 

 

 

 

 

BONE AND JOINT QUESTIONS

 

 

 

Yes

No

17.

Have you ever had an injury to a bone, muscle, ligament, or

 

 

 

 

tendon that caused you to miss a practice or a game?

 

 

 

 

 

18.

Have you ever had any broken or fractured bones or dislocated

 

 

 

 

joints?

 

 

 

 

 

19.

Have you ever had an injury that required x-rays, MRI, CT scan,

 

 

 

 

injections, therapy, a brace, a cast, or crutches?

 

 

 

 

 

20.

Have you ever had a stress fracture?

 

 

 

 

 

21.

Have you ever been told that you have or have you had an x-ray

 

 

 

 

for neck instability or atlantoaxial instability? (Down syndrome or

 

 

 

 

dwarfism)

 

 

 

 

 

22.

Do you regularly use a brace, orthotics, or other assistive device?

 

 

23.

Do you have a bone, muscle, or joint injury that bothers you?

 

 

24.

Do any of your joints become painful, swollen, feel warm, or look

 

 

 

 

red?

 

 

 

 

 

25.

Do you have any history of juvenile arthritis or connective tissue

 

 

 

 

disease?

 

 

 

 

 

MEDICAL QUESTIONS

Yes

No

26.Do you cough, wheeze, or have difficulty breathing during or after exercise?

27.

Have you ever used an inhaler or taken asthma medicine?

 

 

28.

Is there anyone in your family who has asthma?

 

 

29.

Were you born without or are you missing a kidney, an eye, a

 

 

 

testicle (males), your spleen, or any other organ?

 

 

30.

Do you have groin pain or a painful bulge or hernia in the groin

 

 

 

area?

 

 

31.

Have you had infectious mononucleosis (mono) within the last

 

 

 

month?

 

 

32.

Do you have any rashes, pressure sores, or other skin problems?

 

 

33.

Have you had a herpes or MRSA skin infection?

 

 

34.

Have you ever had a head injury or concussion?

 

 

35.

Have you ever had a hit or blow to the head that caused

 

 

 

confusion, prolonged headache, or memory problems?

 

 

36.

Do you have a history of seizure disorder?

 

 

37.

Do you have headaches with exercise?

 

 

38.

Have you ever had numbness, tingling, or weakness in your arms

 

 

 

or legs after being hit or falling?

 

 

39.

Have you ever been unable to move your arms or legs after being

 

 

 

hit or falling?

 

 

40.

Have you ever become ill while exercising in the heat?

 

 

41.

Do you get frequent muscle cramps when exercising?

 

 

42.

Do you or someone in your family have sickle cell trait or disease?

 

 

43.

Have you had any problems with your eyes or vision?

 

 

44.

Have you had any eye injuries?

 

 

45.

Do you wear glasses or contact lenses?

 

 

46.

Do you wear protective eyewear, such as goggles or a face shield?

 

 

47.

Do you worry about your weight?

 

 

48.

Are you trying to or has anyone recommended that you gain or

 

 

 

lose weight?

 

 

49.

Are you on a special diet or do you avoid certain types of foods?

 

 

50.

Have you ever had an eating disorder?

 

 

51.

Have you or any family member or relative been diagnosed with

 

 

 

cancer?

 

 

52.

Do you have any concerns that you would like to discuss with a

 

 

 

doctor?

 

 

FEMALES ONLY

Yes

No

53.

Have you ever had a menstrual period?

 

 

54.How old were you when you had your first menstrual period?

55.How many periods have you had in the last 12 months?

Explain es answe s he e

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete

 

Signature of parent/guardian

 

Date

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503

Pre-participation Examination

PHYSICAL EXAMINATION FORM

 

EXAMINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height

 

 

Weight

 

Male

Female

 

 

 

 

 

 

 

 

BP

/

(

/

)

Pulse

Vision R 20/

L 20/

 

 

Corrected

Y N

 

MEDICAL

 

 

 

 

 

 

 

NORMAL

 

 

ABNORMAL FINDINGS

 

 

 

Appearance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum,

 

 

 

 

 

 

 

 

 

 

arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

 

 

 

 

 

 

 

 

 

Eyes/ears/nose/throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pupils equal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hearing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lymph nodes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Murmurs (auscultation standing, supine, +/- Valsalva)

 

 

 

 

 

 

 

 

 

 

 

Location of point of maximal impulse (PMI)

 

 

 

 

 

 

 

 

 

 

 

Pulses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Simultaneous femoral and radial pulses

 

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Genitourinary (males only)b

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HSV, lesions suggestive of MRSA, tinea corporis

 

 

 

 

 

 

 

 

 

 

 

Neurologic c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUSCULOSKELETAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neck

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Back

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shoulder/arm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elbow/forearm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wrist/hand/fingers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hip/thigh

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Knee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leg/Ankle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foot/toes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duck-walk, single leg hop

 

 

 

 

 

 

 

 

 

 

 

 

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.

 

 

 

 

 

 

 

 

 

bConsider GU exam if in private setting. Having third party present is recommended.

 

 

 

 

 

 

 

 

 

cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

 

 

 

 

 

 

 

 

 

O the

asis of the e a i

atio

o this da

, I appro e this

hild’s parti ipatio i

i ters holasti

sports for o

e year.

 

 

Yes

 

 

 

No

 

Limited

 

 

 

 

 

Examination Date

 

 

Additional Comments:

Ph

si ia

’s Sig ature

 

Ph

si ia

’s Assista t Sig ature*

 

Ad a ed Nurse Pra titio er’s Sig ature*

 

*effective January 2003, the IHSA Board of Dire tors appro ed a re o

e datio , o siste t ith the Illi ois S hool Code, that allo s Ph si ia ’s Assista ts or

Advanced Nurse Practitioners to sign off on physicals.

 

IHSA Steroid Testing Policy Consent to Random Testing

(This section for high school students only)

2011-2012 school term

As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school

day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student’s high school as specified in the IHSA

Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student to penalties as determined by IHSA.

A complete list of the current IHSA Banned Substance Classes can be accessed at

http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes.pdf

 

 

 

 

 

 

 

 

 

 

Signature of student-athlete

 

Date

 

Signature of parent-guardian

 

Date

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