Student's Name Age Grade

SECTION 5 : HEALTH HISTORY

Explain "Yes" answers below. Circle questions you don't know the answers to.

General Questions Yes No
1 Has a doctor ever denied or restricted your participation in sport(s) for any reason?
2 Do you have an ongoing medical condition (like asthma or diabetes)?
3 Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills?
4 Do you have allergies to medicines, pollens, foods, or stinging insects?
5 Have you ever passed out or nearly passed out DURING exercise?
6 Have you ever passed out or nearly passed out AFTER exercise?
7 Have you ever had discomfort, pain, or pressure in your chest during exercise?
8 Does your heart race or skip beats during exercise?
9. 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 
10 Has a doctor ever ordered a test for your heart? (for example ECG, echocardiogram)
11 Has anyone in your family died for no apparent reason?
12 Does anyone in your family have a heart problem?
13 Has any family member or relative been disabled from heart disease or died of heart problems or sudden death before age 50?
14 Does anyone in your family have Marfan Syndrome?
15 Have you ever spent the night in a hospital?
16 Have you ever had surgery?
17 Have you ever had an injury, like a sprain, muscle, or ligament tear, or tendinitis, which caused you to miss a Practice or Contest? If yes, Select the affected areas below:
18 Have you had any broken or fractured bones or dislocated joints? If yes, select below:
19 Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a brace, a cast, or crutches? If yes, check below.
Check all that apply for questions 17-19.
  
 Head   
 Neck   
 Shoulder   
 Upper arm   
 Elbow   
 Forearm   
 Hand fingers   
 Chest   
 Upper back   
 Upper back   
 Upper back   
 thigh   
 knee   
 calf_shin   
 ankle   
 toes_foot 
20 Have you ever had a stress fracture?
21 Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability?
22 Do you regularly use a brace or assistive device?
MEDICAL QUESTIONS Yes No
23 Has a doctor ever told you that you have asthma or allergies?
24 Do you cough, wheeze, or have difficulty breathing DURING or AFTER exercise?
25 Is there anyone in your family who has asthma?
26 Have you ever used an inhaler or taken asthma medicine?
27 Were you born without or are you missing a kidney, an eye, a testicle, or any other organ?
28 Have you had infectious mononucleosis (mono) within the last month?
29 Do you have any rashes, pressure sores, or other skin problems?
30 Have you ever had a herpes skin infection?
CONCUSSION OR TRAUMATIC BRAIN INJURY Yes No
31 Have you ever had a concussion (i.e. bell rung, ding, head rush) or traumatic brain injury?
32 Have you ever been hit in the head and been confused or lost your memory?
33 Do you experience dizziness and/or headaches with exercise?
34 Have you ever had a seizure?
35 Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
36 Have you ever been unable to move your arms or legs after being hit or falling?
37 When exercising in the heat, do you have severe muscle cramps or become ill?
38 Has a doctor told you that you or someone in your family has sickle cell trait or sickle cell disease?
39 Have you had any problems with your eyes or vision?
40 Do you wear glasses or contact lenses?
41 Do you wear protective eye wear, such a goggles or a face shield?
42 Are you unhappy with your weight?
43 Are you trying to gain or lose weight?
44 Has anyone recommended you change your weight or eating habits?
45 Do you limit or carefully control what you eat?
46 Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY Yes No
47 Have you ever had a menstrual period?
How old were you when you had your first menstrual period?
How many periods have you had in the last 12 months?
50 Are you pregnant?
Explain "yes" answers here









I hereby certify that, to the best of my knowledge, all of the information herein is true and complete.

Student’s Signature Date

I hereby certify that, to the best of my knowledge, all of the information herein is true and complete.

Signature of parent/guardian Date
















SECTION 6 : PIAACOMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATIONAND CERTIFICATION OF AUTHORIZED MEDICAL EXAMINER

Must be completed and signed by the Authorized Medical Examiner (AME) performing the herein named student’s comprehensive initial pre-participation physical evaluation (CIPPE) and turned in to the Principal, or the Principal’s designee, of the student's school.

Student's Name Age Grade

Enrolled in Sport(s)

Height    Weight %   Body Fat (optional)    Brachial Artery BP    RP   

If either the brachial artery blood pressure (BP) or resting pulse (RP) is above the following levels, further evaluation by the student’s primary care physician is recommended.

Age 10-12:BP: >126/82, RP: >104; Age 13-15:BP: >136/86, RP >100; Age 16-25:BP: >142/92, RP >96.


Vision:   R 20/ L 20/ Corrected: 
YES
NO    Pupils:   Equal Unequal

Medical Normal ABNORMAL FINDINGS
Appearance
Eyes/Ears/Nose/Throat
Hearing
Lymph Nodes
Cardiovascular
Heart murmur  
Femoral pulses to exclude aortic coarctation  
Physical stigmata of Marfan syndrome
Cardiopulmonary
Lungs
Abdomen
Genitourinary (males only)
Neurological
Skin
MUSCULOSKELETAL Normal ABNORMALFINDINGS
Neck
Back
Shoulder/Arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes

I 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’s parent/guardian in Section 2 of the PIAA Comprehensive Initial Pre-Participation Physical Evaluation form:


 CLEARED  
 CLEARED, with recommendation(s) for further evaluation or treatment for:
 NOT CLEARED for the following types of sports (please check those that apply):
 COLLISION  
 CONTACT  
 NON-CONTACT  
 STRENUOUS   
 MODERATELY STRENUOUS  
 NON-STRENUOUS
Due to:
Recommendation(s)/Referral(s):

AME’s Name (print/type): License #
Address: Phone ( )

AME’s SignatureMD, DO, PAC, CRNP, or SNP (circle one) Certification Date of CIPPE