School: Pd___

Grade: ________ (Rising)

Pitt County Schools Appendix B

Pre-participation Physical Evaluation Side A

Date

Name Sex: M F Age Date of Birth SS#

Address Parents Name Phone #

Personal Physician Address Phone #

Primary Emergency Contact Relationship Phone #

Secondary Emergency Contact Relationship Phone #

Sport(s)

History

Explain “Yes” answers below:	Yes	No
1. Have you ever been hospitalized?.................................................................................................................................	q	q
Have you ever had surgery?..........................................................................................................................................	q	q
2. Are you presently taking any medications or pills?.......................................................................................................	q	q
3. Do you have any allergies (medicine, bees or other stinging insects, latex)?................................................................	q	q
4. Have you ever passed out during or after exercise?.......................................................................................................	q	q
Have you ever been dizzy during or after exercise?.......................................................................................................	q	q
Have you ever had chest pain during or after exercise?..............................................................................................	q	q
Do you tire more quickly than your friends during exercise?........................................................................................	q	q
Have you ever had high blood pressure?.......................................................................................................................	q	q
Have you ever been told that you have a heart murmur?..............................................................................................	q	q
Have you ever had racing of your heart or skipped heartbeats?.....................................................................................	q	q
Has anyone in your family died of heart problems or sudden death before age 50?.........................................................	q	q
5. Do you have any skin problems (itching, rashes, acne)?................................................................................................	q	q
6. Have you ever had a head injury?..................................................................................................................................	q	q
Have you ever been knocked out or unconscious?..........................................................................................................	q	q
Have you ever had a seizure?........................................................................................................................................	q	q
Have you ever had a stinger, burner or pinched nerve?.................................................................................................	q	q
7. Have you ever had heat or muscle cramps?....................................................................................................................	q	q
Have you ever been dizzy or passed out in the heat?......................................................................................................	q	q
8. Do you have trouble breathing or do you cough during or after activity?.......................................................................	q	q
9. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guard, etc.)?..........................................	q	q
10. Have you had any problems with your eyes or vision?...................................................................................................	q	q
11. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury of any bones or joints?............................................................................................................................................................................	q	q
q Head q Shoulder q Thigh q Neck q Elbow q Knee q Chest qHip q Forearm q Shin/calf q Back q Wrist q Ankle q Hand q Foot	q	q
12. Have you ever had an eating disorder, or do you have any concerns about your eating habits or weight?........................	q	q
13. Do you have any chronic medical illnesses (diabetes, asthma, kidney problems, etc.)?...................................................	q	q
14. Have you had a medical problem or injury since your last evaluation?...........................................................................	q	q
15. Do you take any supplements? If so, list.	q	q
16. When was your last tetanus shot?	q	q
When was your last measles immunization?	q	q

WOMEN

17. When was your first menstrual period? When was your last menstrual period?

What was the longest time between your periods last year?

Explain “Yes” answers:

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

Date Signature of Athlete Signature of Parent/Guardian

Note to Parents: This is a screening evaluation only and is not a complete physical examination. It does not substitute for needed regular exams

with your child’s physician. Follow up immunizations; health screening and guidance are important.

Physical form 4/4/05

(The following are considered disqualifying until medical and parental releases are obtained: acute infections, obvious growth retardation, diabetes, jaundice, severe visual or auditory impairment, pulmonary insufficiency, organic heart disease or hypertension, enlarged liver or spleen, hernia, musculoskeletal deformity associated with functional loss, history of convulsions or concussions, absence of one kidney, eye, testicle, or ovary, etc.)

GENERAL		NORMAL		ABNORMAL FINDINGS	INITIALS
	HEENT
	PULSES
	HEART
	LUNGS
	TANNER STAGE (Optional)		1 2 3 4 5
	SKIN
	ABDOMINAL
	GENITALIA (MALES)
	HERNIA (MALES)
MUSCULOSKELETAL
	NECK/BACK
	SHOULDER
	ELBOW
	WRIST/HAND
	KNEE
	HIP
	ANKLE/FOOT