Get Mo Mshsaa Pre-participation Physical Evaluation 2016

Signature of Athlete Signature of Parent s or Guardian Date designed by MSHSAA Sports Medicine Advisory Committee 2011 PHYSICAL EXAMINATION FORM Physician Reminders Consider additional questions on more sensitive issues. Participants must obey all safety rules report all physical and hygiene problems to their coaches follow a proper conditioning program and inspect their own equipment daily. PARENTS GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN MSHSAA- SPONSORED SPORT WITHOUT THE STUDENT S AND PARENT S/GUARDIAN/S SIGNATURE. parent or guardian in the case of the student-athlete being a minor but that if necessary the student-athlete will be transported via ambulance to the nearest hospital. We hereby give our consent for the above student to represent his/her school in interscholastic athletics. HISTORY FORM PRE-PARTICIPATION PHYSICAL EVALUATION Note This form is to be filled out by the patient and parent prior to seeing the physician* The physician should keep a copy of this form in the chart for their records. Date of Exam Name Date of Birth Sex Age Grade School Sport s Medicines and Allergies Please list all of the prescription and over-the-counter medicines and supplements herbal and nutritional that you are currently taking Do you have any allergies Yes No Medicines If yes please identify specific allergy below Pollens Food Stinging Insects Explain Yes answers below. Circle questions you do not know the answer to. GENERAL QUESTIONS Yes No MEDICAL QUESTIONS 1. Has a doctor ever denied or restricted your participation in sports for 26. Do you cough wheeze or have difficulty breathing during or after any reason exercise 2. Do you have any ongoing medical conditions If so please identify 27. Have you ever used an inhaler or taken asthma medicine 28. Is there anyone in your family who has asthma below Asthma Anemia Diabetes Infections 29. Were you born without or are you missing a kidney an eye a testicle Other males or spleen or any other organ 3. Have you ever spent the night in the hospital 30. Do you have groin pain or a painful bulge or hernia in the groin area 4. Have you ever had surgery 31. Have you had infectious mononucleosis mono within the last month HEART HEALTH QUESTIONS ABOUT YOU 33. Have you had a herpes or MRSA skin infection chest during exercise prolonged headaches or memory problems 7. Does your heart ever race or skip beats irregular beats during 36. Do you have a history of seizure disorder 37. Do you have headaches with exercise check all that apply High blood pressure A heart murmur A heart infection legs after being hit or falling High cholesterol Kawasaki disease Other or falling ECG/EKG echocardiogram 41. Do you get frequent muscle cramps when exercising 10. Do you get lightheaded or feel more short of breath than expected 42. Do you or someone in your family have sickle cell trait or disease during exercise 44. Have you had any eye injuries 12.