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New Jersey Department of Education

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION FORM

Part A: HEALTH HISTORY QUESTIONNAIRE-Completed by the parent and student and reviewed by examining provider

Part B: PHYSICAL EVALUATION FORM-Completed by examining licensed provider with MD, DO, APN or PA

Part A: HEALTH HISTORY QUESTIONNAIRE

Today’s Date:_____________________	Date of Last Sports Physical: __________________________


Student’s Name: __________________________________ Sex: M F (circle one)		Age: ____	Grade: ________
Date of Birth: ____/___/_______	School: _____________________________	District: _______________________
Sport(s): _____________________________________________________________________		Home Phone: (_____) ___________

Provider Name (Medical Home): _______________________________ Phone: _______________________ Fax: ____________


	EMERGENCY CONTACT INFORMATION
Name of parent/guardian: _________________________________		Relationship to student: ______________________________
Phone (work): _____________________	Phone (home):______________________________		Phone (cell): ______________
Additional emergency contact: ____________________________		Relationship to student: ______________________________
Phone (work): _____________________	Phone (home):______________________________		Phone (cell): ______________

Directions: Please answer the following questions about the student’s medical history by CIRCLING the correct response. Explain all “yes” responses on the lines below the questions. Please respond to all questions.

1.Have you ever had, or do you currently have:

a. Restriction from sports for a health related problem?		Y / N / Don’t Know
b. An injury or illness since your last exam?		Y / N / Don’t Know
c. A chronic or ongoing illness (such as diabetes or asthma)?		Y / N / Don’t Know
(1.)	An inhaler or other prescription medicine to control asthma?	Y / N / Don’t Know
d. Any prescribed or over the counter medications that you take on a regular basis?		Y / N / Don’t Know
e. Surgery, hospitalization or any emergency room visit(s)?		Y / N / Don’t Know
f. Any allergies to medications?		Y / N / Don’t Know
g. Any allergies to bee stings, pollen, latex or foods?		Y / N / Don’t Know
(1.)	If yes, check type of reaction:
	□ Rash □ Hives □ Breathing or other anaphylactic reaction
(2.)	Take any medication/Epipen taken for allergy symptoms? (List below.)	Y / N / Don’t Know
h. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders? Y / N / Don’t Know
i. A blood relative who died before age 50?		Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates):

List all medications here:

Medication Name	Dosage	Frequency

Part A Page 1 of 3

NJDOE/APPEF Revised 3/10

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

2.Have you ever had, or do you currently have, any of the following head-related conditions:

a. Concussion or head injury (including “bell rung” or a “ding”)?	Y / N / Don’t Know
b. Memory loss?	Y / N / Don’t Know
c. Knocked out?	Y / N / Don’t Know
c. A seizure?	Y / N / Don’t Know
d. Frequent or severe headaches (With or without exercise)?	Y / N / Don’t Know
e. Fuzzy or blurry vision	Y / N / Don’t Know
f. Sensitivity to light/noise	Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates):

____________________________________________________________________________________________________________

3.Have you ever had, or do you currently have, any of the following heart-related conditions:

a. Restriction from sports for heart problems?		Y / N / Don’t Know
b. Chest pain or discomfort?		Y / N / Don’t Know
c.	Heart murmur?	Y / N / Don’t Know
d.	High blood pressure?	Y / N / Don’t Know
e.	Elevated cholesterol level?	Y / N / Don’t Know
f.	Heart infection?	Y / N / Don’t Know
g.	Dizziness or passing out during or after exercise without known cause?	Y / N / Don’t Know

h.Has a provider ever ordered a heart test ( EKG, echocardiogram, stress test, Holter monitor)? Y / N / Don’t Know

i.	Racing or skipped heartbeats?	Y / N / Don’t Know
j.	Unexplained difficulty breathing or fatigue during exercise?	Y / N / Don’t Know

k.Any family member (blood relative):

(1.)	Under age 50 with a heart condition?	Y / N / Don’t Know
(2.)	With Marfan Syndrome?	Y / N / Don’t Know
(3.)	Died of a heart problem before age 50? If yes, at what age? _____________________	Y / N / Don’t Know
(4.)	Died with no known reason?	Y / N / Don’t Know
(5.)	Died while exercising? If yes, was it during or after? (Circle one.)	Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates):

____________________________________________________________________________________________________________

4.Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions:

a. Vision problems?	Y / N / Don’t Know
(1.) Wear contacts, eyeglasses or protective eye wear? (Circle which type.)	Y / N / Don’t Know
b. Hearing loss or problems?	Y / N / Don’t Know
(1.) Wear hearing aides or implants?	Y / N / Don’t Know
c. Nasal fractures or frequent nose bleeds?	Y / N / Don’t Know
d. Wear braces, retainer or protective mouth gear?	Y / N / Don’t Know
e. Frequent strep or any other conditions of the throat (e.g. tonsillitis)?	Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates):

____________________________________________________________________________________________________________

5.Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions:

a. Numbness, a “burner”, “stinger” or pinched nerve?		Y / N / Don’t Know
b.	A sprain?	Y / N / Don’t Know
c.	A strain?	Y / N / Don’t Know
d.	Swelling or pain in muscles, tendons, bones or joints?	Y / N / Don’t Know
e.	Dislocated joint(s)?	Y / N / Don’t Know
f.	Upper or lower back pain?	Y / N / Don’t Know
g.	Fracture(s), stress fracture(s), or broken bone(s)?	Y / N / Don’t Know
h.	Do you wear any protective braces or equipment?	Y / N / Don’t Know

Explain all (yes) answers here (include relevant dates):

____________________________________________________________________________________________________________

Part A Page 2 of 3

NJDOE/APPEF Revised 3/10

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

6.Have you ever had or do you currently have any of the following general or exercise related conditions: a. Difficulty breathing?

(1.)	During exercise?	Y / N / Don’t Know
(2.)	After running one mile?	Y / N / Don’t Know
(3.)	Coughing, wheezing or shortness of breath in weather changes?	Y / N / Don’t Know
(4.)	Exercise-induced asthma?	Y / N / Don’t Know
	i. Controlled with medication? (specify __________________________)	Y / N / Don’t Know
	ii. Experience dizziness, passing out or fainting?	Y / N / Don’t Know
b. Viral infections (e.g. mono, hepatitis, coxsackie virus)?		Y / N / Don’t Know
c. Become tired more quickly than others?		Y / N / Don’t Know
d. Any of the following skin conditions:
(1.)	Cold sores/herpes, impetigo, MRSA, ringworm, warts?	Y / N / Don’t Know
(2.)	Sun sensitivity?	Y / N / Don’t Know
e. Weight gain/loss (of 10 pounds or more)?		Y / N / Don’t Know
(1.)	Do you want to weigh more or less than you do now?	Y / N / Don’t Know
f. Ever had feelings of depression?		Y / N / Don’t Know
g. Heat-related problems (dehydration, dizziness, fatigue, headache)?		Y / N / Don’t Know
(1.)	Heat exhaustion (cool, clammy, damp skin)?	Y / N / Don’t Know
(2.)	Heat stroke (hot, red, dry skin)?	Y / N / Don’t Know
(3.)	Muscle cramps?	Y / N / Don’t Know
h. Absence or loss of an organ (e.g. kidney, eyeball, spleen, testicle, ovary)?		Y / N / Don’t Know

Explain all “yes” answers here (include relevant dates):

__________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

7.	Females only:
	Age of onset of menstruation:______	How many menstrual periods in the last twelve (12) months?		________
		How many periods missed in the last twelve (12) months?		________
8.	Males only:
	Have you had any swelling or pain in your testicles or groin?		Y / N / Don’t Know

PARENT/GUARDIAN SIGNATURE

I certify that the information provided herein is accurate to the best of my knowledge as of the date of my signature.

_______________________________________	_________________
Signature, Parent/Guardian or Student Age 18	Date of Signature:

THIS COMPLETED AND SIGNED HEALTH HISTORY MUST BE REVIEWED BY THE

EXAMINING PROVIDER AT THE TIME OF THE MEDICAL EXAM.

Part A Page 3 of 3

NJDOE/APPEF Revised 3/10

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

ANNUAL ATHLETIC PRE-PARTICIPATION PHYSICAL EVALUATION FORM

Part B: Physical Evaluation Form

(Completed by the examining licensed provider MD, DO, APN or PA)

-STUDENT INFORMATION-

Student’s Name: __________________________________ Sport(s): _____________________________________________________

Sex: M F (circle one) Age: ________ Grade: _____________

Date of Birth: _________________________________________

Address: ___________________________________________________________________________________________________________

City/State/Zip:________________________________________________	Home Phone: _________________________________________
School: _____________________________________________________	District: _____________________________________________

Parent/Guardian’s Full Name: __________________________________________________________________________________________

- EXAMINING PHYSICIAN/PROVIDER CONTACT INFORMATION-

If conducted by school physician check here □
Name: _______________________________			Phone: __________________________			Fax: _________________
Address:______________________________			City/State/Zip:_____________________________________________


		- FINDINGS OF PHYSICAL EVALUATION -
Height: _________	Weight: _________		Blood Pressure: ______/_______ Pulse: _____bpm.
Vision: R 20/____ L 20/ ____		Corrected: Y / N	Contacts: Y / N		Glasses: Y / N

INDICATORS		NORMAL?	ABNORMAL FINDINGS/COMMENTS

General Appearance		YES
Head/Neck		YES
Eyes/Sclera/Pupils		YES
Ears		YES
Gross Hearing		YES
Nose/Mouth/Throat		YES
Lymph Glands		YES
Cardiovascular		YES
Heart Rate		YES
Rhythm		YES
Murmur		ABSENT
If murmur present			Standing makes it:	Louder	Softer	No Change
			Squatting makes it:	Louder	Softer	No Change
			Valsalva makes it:	Louder	Softer	No Change
Femoral Pulses		YES
Lungs: Auscultation/Percussion		YES
Chest Contour		YES
Skin		YES
Abdomen (liver, spleen, masses)		YES
Assessment of physical maturation or		YES
Tanner Scale
Testicular Exam (Males Only)		YES
Neck/Back/Spine:		YES

Range of Motion		YES

Scoliosis		ABSENT

Upper Extremities: (ROM, Strength,		YES
Stability)
Lower Extremities: (ROM, Strength,		YES
Stability)
Neurological: Balance & Coordination		YES
Hernia		ABSENT
Evidence of Marfan Syndrome		ABSENT
		Part B Page 1 of 4
NJDOE/APPEF Revised 3/10		Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

Most recent immunizations and dates administered:

____________________________________________________________________________________________________________

Medications currently prescribed, with dose and frequency:

Medication Name

Dosage

Frequency

Additional observations:

________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

General Diagnosis: ____________________________________________________________________________________________

____________________________________________________________________________________________________________

___________________________________________________________________________________________________________

General Recommendations:

____________________________________________________________________________________________________________

___________________________________________________________________________________________________________

THE HISTORY PREPARED BY THE PARENT/STUDENT MUST BE REVIEWED BY THE EXAMINING PROVIDER AT THE TIME OF THE PHYSICAL EXAMINATION.

Part B Page 2 of 4

NJDOE/APPEF Revised 3/10

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

CLEARANCES: This section is completed by the examining healthcare provider.

After examining the student and reviewing the medical history the student is:

⁪

A.Cleared for participation in all sports without restrictions.

B.Not cleared for participation in any sport until evaluation/treatment of:

___________________________________________________________________________________

C.Cleared for limited participation in the following types of sports only. Please see below for sport classifications. CHECK ALL THAT APPLY

___	CONTACT/COLLISION	___	NON-CONTACT/STRENUOUS
___	LIMITED CONTACT	___	NON-CONTACT/NON-STRENUOUS

Limitations due to: ___________________________________________________________________

________________________________________________

NOTES TO THE EXAMINING PROVIDER

Conditions requiring clearance before sports participation include, but are not limited to the following:

Anaphylaxis; Atlantoaxial instability; Bleeding disorder; Hypertension; Congenital heart disease; Dysrhythmia; Mitral valve prolapse; Heart murmur; Cerebral palsy; Diabetes mellitus; Eating disorders; Heat illness history; One-kidney athletes; Hepatomegaly, Splenomegaly; Malignancy; Seizure Disorder; Marfan’s Syndrome; History of repeated concussion; Organ transplant recipient; Cystic fibrosis; Sickle cell disease; and/or One-eyed athletes or athletes with vision greater than 20/40 in one eye.

SAMPLES OF CLASSIFICATION OF SPORTS BY CONTACT

Contact/Collision	Limited Contact	Non-Contact
		Strenuous	Non-strenuous
Basketball	Baseball	Discus	Bowling
Diving	Cheerleading	Javelin	Golf
Field Hockey	Fencing	Shot put
Football	High Jump	Rowing
Ice Hockey	Pole vault	Running/Cross Country
Lacrosse	Gymnastics	Strength Training
Soccer	Skiing	Swimming
Wrestling	Softball	Tennis
	Volleyball	Track

Effects of physiologic maneuvers on heart sounds			Physical Stigmata of Marfan’s Syndrome
Standing		Increases murmur of HCM	Kyphosis
		Decreases murmur of AS, MR	High arched palate
		MVP click occurs earlier in systole	Pectus excavatum
			Arachnodactyly
Squatting		Increases murmur of AS, MR, AI	Arm span > height 1.05:1 or greater
		Decreases murmur of MCH	Mitral Valve Prolapse
		MVP click delayed	Aortic Insufficiency
			Myopia
Valsalva		Increases murmur of HCM	Lenticular dislocation
		Decreases murmur of AS, MR
		MVP click occurs earlier in systole
HCM:	Hypertrophic Cardio Myopathy
AS:	Aortic Stenosis
AI:	Aortic Insufficiency
MR:	Mitral Regugitation
MVP:	Mitral Valve Prolapse

	Part B Page 3 of 4
NJDOE/APPEF Revised 3/10	Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

HISTORY REVIEWED AND STUDENT EXAMINED BY:

Physician’s/Provider’s Stamp:

฀Primary Care Provider

฀School Physician Provider

฀License Type:

฀MD/DO

฀APN

฀PA

PHYSICIAN’S/PROVIDER’S SIGNATURE: __________________________________________________

Today’s Date: ______________

Date of Exam: ______________

RESERVED FOR SCHOOL DISTRICT USE

NOTE: N.J.A.C. 6A:16-2.2 requires the school physician to provide written notification to the parent/legal guardian stating approval or disapproval of the student’s participation in athletics based on this physical evaluation. This evaluation and the notification letter become part of the student’s school health record.


History and Physical Reviewed By:	__________________________________			Date: _______________
Title of Reviewer (please check one):	฀ School Nurse	฀ School Physician
Medical Eligibility Notification Sent to Parent/Guardian by School Physician			______________________

Date

฀ Letter of notification is attached.

Parent notification indicates that:

฀Participation Approved without limitations.

฀Participation Approved with limitations pending evaluation.

฀Participation NOT Approved

Reason(s) for Disapproval: ____________________________________________________________

_____________________________________________________________________________________

Part B Page 4 of 4

NJDOE/APPEF Revised 3/10

Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

Question	Answer
Form Name	Nj Sports Phisical Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	new jersey school physical form, nj sports form, school physical form, sports physical form state of new jersey

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