Penn State Harrisburg

?64770095250SPORTS MEDICINE INITIAL PRE-PARTICIPATION EXAMINATION FORM00SPORTS MEDICINE INITIAL PRE-PARTICIPATION EXAMINATION FORMName: _________________________________________________________ Sport: _____________________________________Family HistoryHas anyone in your family ever had diabetes (high blood sugar)?Yes o No oHas anyone in your immediate family ever had sudden death (age less than 50)?Yes o No oHas anyone in your immediate family ever had high blood pressure or high cholesterol?Yes o No oHas anyone in your immediate family ever had a heart attack (age less than 50)?Yes o No oHas anyone in your immediate family ever had asthma?Yes o No oDoes anyone in your immediate family or sick cell anemia?Yes o No oHas anyone in your immediate family ever had convulsions (seizures) or epilepsy?Yes o No oHas anyone in your immediate family ever had hypertophic cardiomyopathy, Long QT syndrome, Yes o No oMarfans, or arrhythmias?If you said yes to any of the above questions (1-7), please explain: __________________________________________________________________________________________________________________________________________________________________Personal Medical HistoryHave you ever had or do you now have chest pain with or after exercise?Yes o No oHave you ever had or do you now have dizziness or headaches with or after exercise?Yes o No oHave you ever had or do you now have high blood pressure?Yes o No oHave you ever had or do you now have racing of the heart/irregular rhythm?Yes o No oHave you ever had or do you now have wheezing/cough with exercise, or asthma?Yes o No oHave you ever had or do you now have a heart murmur?Yes o No oHave you ever had or do you now have weakness, fatigue, or anemia?Yes o No oHave you had or do you now have hearing loss or perforated eardrum?Yes o No oHave you had or do you now have dental plate or orthodontic work?Yes o No oHave you had or do you now have impaired vision, wear glasses/contacts?Yes o No oHave you had or do you now have a hernia?Yes o No oHave you had or do you now have kidney disease or damage?Yes o No oHave you had or do you now have a single kidney/eye/testicle or any other paired organ? Yes o No oDo you have migraines or headaches?Yes o No oHas a physician ever denied or restricted you from play?Yes o No oHave you ever had an echo?Yes o No oHave you ever lost consciousness?Yes o No oHave you ever been hit in the head with loss of consciousness or amnesia after?Yes o No o Have you ever had a concussion or traumatic brain injury (bell ring/ding)?Yes o No oHave you ever had a “stinger”, “burner”, or “pinched nerve”?Yes o No oHave you ever had convulsions (seizures) or epilepsy?Yes o No oHave you ever had a neck injury?Yes o No oHave you ever been hospitalized for a medical problem?Yes o No oHave you ever had infectious mononucleosis?Yes o No oHave you ever had heat exhaustion or intolerance?Yes o No oHave you ever been hospitalized or had surgery?Yes o No oHave you ever had or do you now have depression or anxiety?Yes o No oHave you ever had or do you now have thoughts about or attempted suicide?Yes o No oIf you said yes to any of the above questions (8-36), please explain: ____________________________________________________Musculoskeletal InjuriesHave you ever broken a bone?Yes o No oHave you ever had a stress fracture?Yes o No oHave you ever had a muscle injury?Yes o No oHave you ever had a knee injury?Yes o No oHave you ever had a shoulder injury?Yes o No oHave you ever had a back injury?Yes o No oHave you ever seen a chiropractor?Yes o No oHave you ever had a foot injury?Yes o No oHave you ever had an ankle injury?Yes o No oHave you ever injured a joint not listed above?Yes o No oIf you said yes to any of the above questions (37-46), please explain: _______________________________________________________________________________________________________________________________________________________________Medication and AllergiesAre you currently taking any medications (this includes vitamins, over the counter Yes o No o medications, supplements, and birth control pills)?If yes, please list: ________________________________________________________________________________________Are you allergic to any medications?Yes o No oIf yes, please list: ________________________________________________________________________________________Do you have any other allergies?Yes o No oIf yes, please list: ________________________________________________________________________________________Immunization HistoryPlease attach a copy of your current immunizations.Females OnlyAt what age did you have your first menstrual cycle?_________________How many days do you have menstrual bleeding?_________________Typically, how many days is your menstrual cycle?_________________How many periods have you had in the past 12 months?_________________Have you ever had cramping with your period that required treatment?Yes o No oHave you ever had irregular cycles?Yes o No oHave you ever had heavy bleeding?Yes o No oHave you ever had a PAP or pelvic exam?Yes o No oIf so, have you ever had an ABNORMAL pelvic exam or PAP smear?Yes o No oAre you currently taking oral contraceptives or hormones?Yes o No oWhat is the primary reason you are currently taking oral contraceptives or hormones?_________________Has a physician ever told you that you had anemia (low hematocrit or iron)?Yes o No oIf you said yes to any of the above questions (51-62), please explain: _______________________________________________________________________________________________________________________________________________________________Background InformationWhat is your current year in college? (please circle): 1 2 3 4 5 6 graduate studentWhat is your ethnic/racial group? (please circle): American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Other: _________________________Health HabitsHave you in the past or do you currently use cigarettes, chewing tobacco, or other tobacco products? Yes o No oHave you in the past or do you currently use marijuana/Spice/THC?Yes o No oHave you in the past or do you currently use amphetamines/stimulants?Yes o No oHave you in the past or do you currently use other recreational drugs?Yes o No oHave you in the past or are you currently being treated for a drug problem?Yes o No oDo you have any drug-related concerns that you would like to discuss with a medical professional?Yes o No oDo you have concerns about family members with drug use/abuse problems?Yes o No oHave you in the past or do you currently use steroids?Yes o No oHave you in the past or do you currently use alcohol?Yes o No oIf so, how often?_________________Have you in the past or are you currently being treated for an alcohol problem?Yes o No oDo you have any alcohol-related concerns that you would like to discuss with a medical professional? Yes o No oAre you sexually active?Yes o No oDo you have a history of more than 2 sexual partners in the last 6 months?Yes o No oDo you have a history of any sexually transmitted disease?Yes o No oDo you have any questions or concerns about HIV?Yes o No oIf you said yes to any of the above questions (65-80), please explain: _______________________________________________________________________________________________________________________________________________________________NutritionAre you happy with your present weight?Yes o No oIf you are not happy with your present weight, do you have concerns?Yes o No oIf you are not happy with your present weight, what is your desired weight in pounds? _________________Does weight affect the way you feel about yourself?Yes o No oDo you ever eat in secret?Yes o No oDo you worry that you have lost control over how much you eat?Yes o No oDo you try to lose weight to meet weight or image/appearance requirements for your sport? Yes o No oHave you ever tried to control your weight by excessive exercise?Yes o No oHave you ever tried to control your weight by vomiting?Yes o No oHave you ever tried to control your weight by using diet pills?Yes o No oHave you ever tried to control your weight by using laxatives or diuretics?Yes o No oHave you ever tried to control your weight by dieting/fasting?Yes o No oHave you ever had an eating disorder?Yes o No oIf you said yes to any of the above questions (81-93), please explain: _______________________________________________________________________________________________________________________________________________________________General 94. Do you have any other conditions that our medical staff should know about, including autoimmune and anything not included above? Yes ___ No ___If you said yes to question 94, please explain: ____________________________________________________________________________________________________________Honesty WaiverI declare that all of the above information is true to the best of my knowledge. Recognizing that my true physical condition is dependent on an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in this questionnaire any knowledge of my condition in my answers.Sign and date: ____________________________________________Created 6/27/20132276475-9525000Updated 4/24/2020704850110490COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION 00COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION Student’s Name: _________________________________________________________ Age: ________ Year: _________________Sport(s): ____________________________________________________________________________________________________Height: ________ Weight: ________ Brachial Artery BP: ______/______ (______/______, ______/______) RP: _____________ MEDICALNORMALABNORMAL FINDINGSAppearanceEyes/Ears/Nose/ThroatHearingLymph NodesCardiovascularo Heart murmur o Femoral pulses to exclude aortic coarctation o Physical stigmata of Marfan SyndromeCardiopulmonaryLungsAbdomenGenitourinary (males only)NeurologicalSkinMUSCULOSKELETALNORMALABNORMAL FINDINGSNeckBackShoulder/ArmElbow/ForearmWrist/Hand/FingersHip/ThighKneeLeg/AnkleFoot/ToesI hereby certify that I have reviewed the Health History, performed a comprehensive initial pre-participation physical evaluation of the herein named student, and, on the basis of such evaluation and the student’s Health History, certify that, except as specified below, the student is physically fit to participate in Practices, Inter-School Practices, Scrimmages, and/or Contests in the sport(s) consented to by the student:o CLEARED o CLEARED, with recommendation(s) for further evaluation or treatment for: ___________________________________________o NOT CLEARED, for the following types of sports (please check those that apply):o Collision o Contact o Non-Contact o Strenuous o Moderately Strenuous o Non-StrenuousDue to: __________________________________________________________________________________________________Recommendation(s)/Referral(s): ______________________________________________________________________________Physician’s Name (print): ______________________________________________________ Physician’s Signature: ________________________________________________________________ o MD, o DO, o PAC, o CRNP Date _________________ Created 6/27/2013 ................
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