Sports Pre-Participation Examination – Athlete or Parent Section

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posted 2017-03-01, updated 2019-12-22
Pediatrics, Subjective/History Elements
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[comment memo="Instructions to Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability."]
[text size=40 default="Name of Athlete"]
[text size=40 default="Name of Person Completing this Form"]

[select name="Q1" value="NO|YES|DO NOT KNOW"]  <-- 1. Has anyone in the athlete’s family died suddenly before the age of 50 years?[conditional field="Q1" condition="(Q1).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q2" value="NO|YES|DO NOT KNOW"]  <-- 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?[conditional field="Q2" condition="(Q2).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q3" value="NO|YES|DO NOT KNOW"]  <-- 3. Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen?[conditional field="Q3" condition="(Q3).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q4" value="NO|YES|DO NOT KNOW"]  <-- 4. Is the athlete allergic to any medications or bee stings?[conditional field="Q4" condition="(Q4).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q5" value="NO|YES|DO NOT KNOW"]  <-- 5. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?[conditional field="Q5" condition="(Q5).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q6" value="NO|YES|DO NOT KNOW"]  <-- 6. Has the athlete ever had a head injury or concussion?[conditional field="Q6" condition="(Q6).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q7" value="NO|YES|DO NOT KNOW"]  <-- 7. Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache?[conditional field="Q7" condition="(Q7).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q8" value="NO|YES|DO NOT KNOW"]  <-- 8. Has the athlete ever suffered a heat‐related illness (heat stroke)?[conditional field="Q8" condition="(Q8).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q9" value="NO|YES|DO NOT KNOW"]  <-- 9. Does the athlete have a chronic illness or see a physician regularly for any particular problem?[conditional field="Q9" condition="(Q9).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q10" value="NO|YES|DO NOT KNOW"]  <-- 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements?[conditional field="Q10" condition="(Q10).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q11" value="NO|YES|DO NOT KNOW"]  <-- 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)?[conditional field="Q11" condition="(Q11).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q12" value="NO|YES|DO NOT KNOW"]  <-- 12. Has the athlete ever had prior limitation from sports participation?[conditional field="Q12" condition="(Q12).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q13" value="NO|YES|DO NOT KNOW"]  <-- 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily?[conditional field="Q13" condition="(Q13).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q14" value="NO|YES|DO NOT KNOW"]  <-- 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension?[conditional field="Q14" condition="(Q14).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q15" value="NO|YES|DO NOT KNOW"]  <-- 15. Is there a history of young people in the athlete’s family who have had heart disease: examples are cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome? [conditional field="Q15" condition="(Q15).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q16" value="NO|YES|DO NOT KNOW"]  <-- 16. Has the athlete ever been hospitalized overnight or had surgery?[conditional field="Q16" condition="(Q16).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q17" value="NO|YES|DO NOT KNOW"]  <-- 17. Does the athlete lose weight regularly to meet the requirements for your sport?[conditional field="Q17" condition="(Q17).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q18" value="NO|YES|DO NOT KNOW"]  <-- 18. Does the athlete have anything he or she wants to discuss with the physician?[conditional field="Q18" condition="(Q18).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q19" value="NO|YES|DO NOT KNOW"]  <-- 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity?[conditional field="Q19" condition="(Q19).is('YES')"]
[text size=40 default="please explain"][/conditional]
[select name="Q20" value="NO|YES|DO NOT KNOW"]  <-- 20. Is the athlete unhappy with his or her weight?[conditional field="Q20" condition="(Q20).is('YES')"]
[text size=40 default="please explain"][/conditional]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][link memo="Mirabelli MH, Devine MJ, Singh J, Mendoza M. The Preparticipation Sports
Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-6." url="https://www.ncbi.nlm.nih.gov/pubmed/26371570"][/conditional]
Instructions to Athlete and Parent/Guardian: Please review all questions and answer them to the best of your ability.



<-- 1. Has anyone in the athlete’s family died suddenly before the age of 50 years?
<-- 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?
<-- 3. Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen?
<-- 4. Is the athlete allergic to any medications or bee stings?
<-- 5. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?
<-- 6. Has the athlete ever had a head injury or concussion?
<-- 7. Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache?
<-- 8. Has the athlete ever suffered a heat‐related illness (heat stroke)?
<-- 9. Does the athlete have a chronic illness or see a physician regularly for any particular problem?
<-- 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements?
<-- 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)?
<-- 12. Has the athlete ever had prior limitation from sports participation?
<-- 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily?
<-- 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension?
<-- 15. Is there a history of young people in the athlete’s family who have had heart disease: examples are cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome?
<-- 16. Has the athlete ever been hospitalized overnight or had surgery?
<-- 17. Does the athlete lose weight regularly to meet the requirements for your sport?
<-- 18. Does the athlete have anything he or she wants to discuss with the physician?
<-- 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity?
<-- 20. Is the athlete unhappy with his or her weight?
display/hide references

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