Illinois Pre Participation Physical Form – Fill Out and Use This PDF

Illinois Pre Participation Physical Form is a great way to ensure that you're in good health before joining high school sports.

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Illinois Pre Participation Physical Form PDF 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

Question	Answer
Form Name	Illinois Pre Participation Physical Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	216
Avg. time to fill out	21 min 53 sec
Other names	ihsa sports 2021, ihsa sports form, printable sports physical form illinois, illinois sports physical form 2020

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

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

(

)

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

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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Illinois Pre Participation Physical Form – Fill Out and Use This PDF

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