Fill a Valid Illinois Pre Participation Physical Form

GENERAL QUESTIONS

Yes

No

1.

Has a doctor ever denied or restricted your participation in sports

for any reason?

2.

Do you have any ongoing medical conditions? If so, please identify

below:  Asthma  Anemia  Diabetes  Infections

Other: _

__________

3.

Have you ever spent the night in the hospital?

4.

Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU

Yes

No

5.

Have you ever passed out or nearly passed out DURING or AFTER

exercise?

6.

Have you ever had discomfort, pain, tightness, or pressure in your

chest during exercise?

7.

Does your heart ever race or skip beats (irregular beats) during

exercise?

8.

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  Kawasaki disease

Other: ___

______

9.

Has a doctor ever ordered a test for your heart? (For example,

ECG/EKG, echocardiogram)

10.

Do you get lightheaded or feel more short of breath than

expected during exercise?

11.

Have you ever had an unexplained seizure?

12.

Do you get more tired or short of breath more quickly than your

friends during exercise?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

Yes

No

13.

Has any family member or relative died of heart problems or had

an unexpected or unexplained sudden death before age 50

(including drowning, unexplained car accident, or sudden infant

death syndrome)?

14.

Does anyone in your family have hypertrophic cardiomyopathy,

Marfan syndrome, arrhythmogenic right ventricular

cardiomyopathy, long QT syndrome, short QT syndrome, Brugada

syndrome, or catecholaminergic polymorphic ventricular

tachycardia?

15.

Does anyone in your family have a heart problem, pacemaker, or

implanted defibrillator?

16.

Has anyone in your family had unexplained fainting, unexplained

seizures, or near drowning?

BONE AND JOINT QUESTIONS

Yes

No

17.

Have you ever had an injury to a bone, muscle, ligament, or

tendon that caused you to miss a practice or a game?

18.

Have you ever had any broken or fractured bones or dislocated

joints?

19.

Have you ever had an injury that required x-rays, MRI, CT scan,

injections, therapy, a brace, a cast, or crutches?

20.

Have you ever had a stress fracture?

21.

Have you ever been told that you have or have you had an x-ray

for neck instability or atlantoaxial instability? (Down syndrome or

dwarfism)

22.

Do you regularly use a brace, orthotics, or other assistive device?

23.

Do you have a bone, muscle, or joint injury that bothers you?

24.

Do any of your joints become painful, swollen, feel warm, or look

red?

25.

Do you have any history of juvenile arthritis or connective tissue

disease?

MEDICAL QUESTIONS

Yes

No

27.

Have you ever used an inhaler or taken asthma medicine?

28.

Is there anyone in your family who has asthma?

29.

Were you born without or are you missing a kidney, an eye, a

testicle (males), your spleen, or any other organ?

30.

Do you have groin pain or a painful bulge or hernia in the groin

area?

31.

Have you had infectious mononucleosis (mono) within the last

month?

32.

Do you have any rashes, pressure sores, or other skin problems?

33.

Have you had a herpes or MRSA skin infection?

34.

Have you ever had a head injury or concussion?

35.

Have you ever had a hit or blow to the head that caused

confusion, prolonged headache, or memory problems?

36.

Do you have a history of seizure disorder?

37.

Do you have headaches with exercise?

38.

Have you ever had numbness, tingling, or weakness in your arms

or legs after being hit or falling?

39.

Have you ever been unable to move your arms or legs after being

hit or falling?

40.

Have you ever become ill while exercising in the heat?

41.

Do you get frequent muscle cramps when exercising?

42.

Do you or someone in your family have sickle cell trait or disease?

43.

Have you had any problems with your eyes or vision?

44.

Have you had any eye injuries?

45.

Do you wear glasses or contact lenses?

46.

Do you wear protective eyewear, such as goggles or a face shield?

47.

Do you worry about your weight?

48.

Are you trying to or has anyone recommended that you gain or

lose weight?

49.

Are you on a special diet or do you avoid certain types of foods?

50.

Have you ever had an eating disorder?

51.

Have you or any family member or relative been diagnosed with

cancer?

52.

Do you have any concerns that you would like to discuss with a

doctor?

FEMALES ONLY

Yes

No

53.

Have you ever had a menstrual period?