Standard Physical Form – Fill Out and Use

					O.K. Conference
				Pre-Participation Physical Exam Form
		Medical Examination
	THIS SIDE TO BE COMPLETED BY EXAMINING MEDICAL PROFESSIONAL
	Name:				Date:
Ht:__________ Wt:___________ HR:___________ BP:___________ BP reck:___________
Corrective Lenses: Y or N		Vision: R________ L________
	Physical Exam	Normal	Abnormal
	General Appearance
	HEENT
	Lymph Nodes
	Heart
	Pulses
	Lungs
	Abdomen
	Skin
	Neurologic
	Spine
	Upper Extremity
	Lower Extremity
	Joint Specific (optional)
	Hernia (males only)
		COMMENTS
	General Medical			Musculoskeletal

RECOMMENDATIONS:

1.[ ] CLEARED WITHOUT RESTRICTIONS

2.[ ] Cleared for LIMITED PARTICIPATION (specify)_______________________________________

_________________________________________________________________________________

3.[ ] NOT CLEARED for participation (explanation) ________________________________________

_________________________________________________________________________________

4.[ ] Requires further evaluation before final recommendation ________________________________

_________________________________________________________________________________

I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activity as dictated by the clearance recommendations above.

Printed Name:______________________________________________ Date:__________________

Signature:_________________________________________________ MD, DO, PA, or NP

A Current-Year Physical is one given on or after April 15 of the previous school year.

O.K. Conference

Pre-Participation Physical Exam Form

Emergency Information

		School: _____________________
Name:__________________________________ DOB:__________ Gender: M F			Grade:________
Parent/Legal Guardian Name(s):_______________________________________________________
Address:__________________________________________________________________________
Street	City	State	Zip

Phone #s: Home:__________________ Work:___________________ Cell:____________________

Emergency Contact(s):

Name:________________________________ Relationship:____________ Phone:_______________

Name:________________________________ Relationship:____________ Phone:_______________

Insurance Information:

Family Insurance Co.:__________________________________________ Phone:_______________

Contract/Group #:___________________________ Policy #:_________________________________

Parent/Legal Guardian Consent & Assumption of Risk:

Participation in interscholastic athletics requires an acceptance of risk of injury. These risks include, but are not limited to the following: death, quadriplegia, paraplegia, internal injury, closed head injury (possibly including post-concussion syndrome) and musculo-skeletal injuries (including sprains, strains, and fractures). Some of these injuries may result in medical treatment, surgery, and/or permanent disability. I understand that coaches, athletic trainers, and physicians (including side-line team physicians) will use their professional judgment when administering proper medical treatment. I have had the opportunity to ask questions, hereby recognize the risk of injury, and give my consent for my son/daughter to participate in interscholastic athletics. I further consent for the disclosure of information otherwise protected by FERPA and HIPPA for the purpose of determining eligibility for interscholastic athletics to the MHSAA, OK Conference, and school district. I also agree to accept and comply with all MHSAA, OK Conference, and school district athletic policies.

Parent/Legal Guardian Signature:_______________________________________ Date:___________

Student-Athlete Signature:_____________________________________________Date:___________

Authorization of Treatment:

I, ________________________________, hereby give my permission for my son/daughter, ____________________________,

to undergo medical treatment for any injury or illness he/she may sustain or acquire while participating in interscholastic athlet- ics. I understand that medical personnel, including athletic trainers and sideline team physicians, will perform only those proce- dures within their training, credentialing, and scope of professional practice to prevent, care for, and rehabilitate athletic injuries or illnesses. In the event more serious medical treatment/procedures are required and I cannot be reached for my consent, I authorize any licensed medical practitioner to perform such treatments/procedures medically necessary to alleviate the problem.

Parent/Legal Guardian Signature:_______________________________________ Date:___________

A Current-Year Physical is one given on or after April 15 of the previous school year.

Medical History
1. Do you have any chronic or ongoing medical conditions?	Yes	No

If yes, explain:____________________________________________________________________

2. Have you ever been hospitalized and/or had surgery for any reason?Yes No If yes, explain:____________________________________________________________________

3. Do you have any allergies (medications, insects, foods, etc.)?Yes No If yes, explain:____________________________________________________________________

4. Are you currently taking any medications or supplements (include over-the-counter)? Yes No If yes, explain:____________________________________________________________________

5. Have you had a medical problem or injury since your last physical exam?Yes No If yes, explain;____________________________________________________________________

6. Have you ever passed out or nearly passed out during or after exercise?	Yes	No
Have you ever had chest pain, tightness, or pressure during or after exercise?	Yes	No
Have you ever been dizzy or light headed during or after exercise?	Yes	No
Do you get more tired or short of breath than others during exercise?	Yes	No
Does your heart ever race or skip beats (irregular beats) during exercise?	Yes	No
Has a doctor ever ordered a test for your heart (e.g. ECG/EKG, echocardiogram?	Yes	No

Have you ever been told you have any of the following (check all that apply):

High blood pressure	Heart murmur	High cholesterol
A heart infection	Kawasaki disease	Other:_____________________

Explain ALL yes answers & checked items:_____________________________________________

_______________________________________________________________________________

7. Has anyone in your family died suddenly OR of heart problems before age 50?	Yes	No
Do anyone in your family have a heart problem, pacemaker, or implanted defibrillator? Yes		No
Has anyone in your family had unexplained fainting, seizures, or near drowning?	Yes	No

Does anyone in your family have any of the following cardiovascular conditions:

Hypertrophic cardiomyopathy	Marfan syndrome	Brugada syndrome
Arrythmogenic right ventricular cardiomyopathy		Long QT syndrome
Catecholaminergic polymorphic ventricular tachycardia		Short QT syndrome

Explain ALL yes answers & checked items:_____________________________________________

_______________________________________________________________________________

8. Have you ever had a concussion, head injury, or recurrent headaches?Yes No If yes, explain:____________________________________________________________________

Have you ever been knocked out or unconscious?Yes No If yes, explain:____________________________________________________________________

Do you have headaches with exercise?Yes No If yes, explain:____________________________________________________________________

Have you ever had any of the following after a hit, blow to the head, or falling:

Confusion

Prolonged headache

Inability to move your arms or legs

Memory problems Numbness, tingling, or weakness in your arms or legs

Explain ALL checked items (include dates):_____________________________________________

_______________________________________________________________________________

Have you ever had a stinger, burner, or pinched nerve?Yes No If yes, explain:____________________________________________________________________

Have you ever had seizures, convulsions, or a history of epilepsy?Yes No If yes, explain:____________________________________________________________________

9. Have you ever become ill, dizzy, or passed out while exercising in the heat?Yes No If yes, explain:____________________________________________________________________

Do you get frequent muscle or heat cramps when exercising?Yes No If yes, explain:____________________________________________________________________

Do you or someone in your family have sickle cell trait or disease?Yes No If yes, explain:____________________________________________________________________

10.Do you or someone in your family have asthma or another obstructive lung disorder? Yes No If yes, explain:____________________________________________________________________

Do you cough, wheeze, or have difficulty breathing during or after exercise?Yes No If yes, explain:____________________________________________________________________

Have you ever used an inhaler or taken asthma medication?Yes No If yes, explain:____________________________________________________________________

11.Do you currently have, or have you EVER HAD any of the following:

Hernia Mononucleosis Diabetes Kidney disease Scoliosis Absent spleen Explain ALL checked items (include dates):_____________________________________________

_______________________________________________________________________________

12.Are you missing one of a set of paired organs (kidneys, eyes, ovaries, testes, etc.)? Yes No If yes, explain:____________________________________________________________________

13.Have you ever sprained, strained, dislocated, fractured, broken, experienced repeated swelling in, had a stress fracture in, or otherwise injured any bones or joints? (check all that apply)

Head	Neck	Chest/ribs	Back	Shoulder	Forearm	Elbow Wrist
Hip	Thigh	Calf/shin	Knee	Ankle	Foot/toes	Hand/fingers

Explain ALL checked answers (include dates):__________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

14.Have you ever had a condition/injury that required x-rays, MRI, CT scan, or therapy? Yes No If yes, explain:____________________________________________________________________

15.Do you use any special equipment (braces, pads, mouthguards, neck rolls, etc.)? Yes No If yes, explain:____________________________________________________________________

16.Have you had any problems with your vision or injuries to your eyes?	Yes	No
Do you wear glasses, corrective lenses, or protective eyewear?	Yes	No

Explain ALL yes answers:___________________________________________________________

17.Have you ever had any skin problems (rashes, itching, MRSA, herpes, acne)?Yes No If yes, explain:____________________________________________________________________

18.Have you ever had an eating disorder or restricted food to lose weight?	Yes	No
Do you want to weigh MORE or LESS than you do now?	Yes	No
Do you feel stressed?	Yes	No

Explain ALL yes answers:___________________________________________________________

20.FEMALES ONLY Age at 1st menstrual period?___________ Date of most recent?____________

Number of periods in the last 12 months?________ Longest time between periods?__________

21.Has a doctor ever denied or restricted your participation in sports for any reason? Yes No If yes, explain;____________________________________________________________________

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

Signature of Athlete:_____________________________________________ Date:_____________

Signature of Parent/Guardian:______________________________________ Date:____________