IHSAA-Physical-Form-23-24.pdf

Physical

MUST

be

performed

after

April

1st

for

the

2023-2024

school

year.

PREPARTICIPATION

PHYSICAL

4th

Edition,

American

Academy

of

Pediatrics

HISTORY

FORM

Note:

Complete

and

sign

this

form

(with

your

parents

if

younger

than

18)

before

your

appointment.

History

Form

is

retained

by

physician/healthcare

provider.

.

Name:

Date

of

birth:

Date

of

examination:

Grade:

Sex

assigned

at

birth

(E

M,

or

intersex);

____

How

do

you

identify

your

gender?

(K,

M,

or

other):

List

past

and

current

medical

conditions.

Have

you

ever

had

surgery?

It

yes,

list

all

past

surgical

procedures.

Medicines

and

supplements:

List

all

current

prescriptions,

over-the-counter

medicines,

and

supplements

(herbal

and

nutritional).

Do

you

have any

allergies?

If

yes,

please

list

all

your

allergies

(ie.

Medicines,

pollens,

food,

stinging

insects),

Are

your

required

vaccinations

current?

Patient

Health

Questionnaire

Version

4

(PHQ-4)

Overall,

during

the

last

2

weeks,

how

often

have

you

been

bothered

by

any

of

the

-

following

problems?

(Circle

Response.)

Not

at

all

Several

Days

Over

half

the

days

Nearly

every

day

Feeling

nervous,

anxious,

or

on

edge

0

1

2

3

Not

being

able

to

stop

or

control

worrying

0

1

2

3

Little

interest

or

pleasure

in

doing

things

0

1

2

3

Feeling

down,

depressed,

or

hopeless

0

1

2

3

(A

sum

of

2

3

is

considered

positive

on

either

subscale

[questions

1

and

2,

or

questions

3

and

4]

for

screening

purposes.)

»

(HEART

HEALTH

QUESTIONS

ABOUT

YOUN

Ici

iNisie.

oe

os:

yuo)

ree

(Explain

~

Yes

answers

at

the

end

of

this

form,

Circle

|

Yes

Ifo)

MAO

MG

Zep

Morals

eel

\(CONTINUED)

9.

Do

you

get

light-headed

or

feel

shorter

of

breath

than

your

friends

during

exercise?

1,

Do

you

have

any

concerns

that

you

would

like

2

:

to

discuss

with

your

provider?

10.

Have

you

ever

had

a

seizure?

2,

Has

a

provider

ever

denied

or

restricted

your

par-

han

ART

mid

ues

OUEST!

fen

Ween

ae

ae>

s

ticipation

in

sports

for

any

reason?

|

|

YOUR

FAMILY:

3.

Do

you

have

any

ongoing

medical

issues

or

recent

illness?

ie

ety

VU

HEALTH

QUESTIONS

N:To}oin

sdel0)

11.

Has

any

fuiaily

tember

or

relative

died

of

heart

problems

or

had

an

unexpected

or

unex-

plained

sudden

death

before

age

35

years

(including

4.

Haye

you

ever

passed

out

or

neatly

passed

out

drowning

or

unexplained

car

crash)?

during

or

after

exercise?

12,

Does

anyone

in

your

family

have

a

genetic

heart

5.

Have

you

ever

had

discomfort,

pain,

tightness,

or

problem

such

as

hypertrophic

cardiomyopathy

pressure

in

your

chest

during

exercise?

(CM)

,

Marfan

syndrome,

archythmogentc

right

ventricular

cardiomyopathy

(ARVC),

long

QT

6.

Does

your

heart

ever

race,

flutter

in

your

chest,

or

syndrome

(LQTS),

short

QT

syndrome

(SQTS),

Bru-

skip

beats

(irregular

beats)

during

exercise?

|]

gada

syndrome,

or

catecholaminergic

poly-morphic

7.

Has

a

doctor

ever

told

you

that

you

have

any

heart

ventricular

tachycardia

(CPVT)?

problems?

13.

Has

anyone

in

your

family

had

a

pacemaker

or

8.

Has

a

doctor

ever

requested

a

test

for

your

heart?

an

implanted

defibrillator

before

age

35?

For

example,

electrocardiography

(ECG)

or

echocardiography.

(1

of

5)

aCe

pi

VsioiKe)

Vi

eieeshi

THON

UCCLeNGTN

foie)

pe

14,

Hovey

you

ever

had

a

stress

fracture

or

an

injury

25.

Do

you

worry

about

your

weight?

to

a

bone,

muscle,

ligament,

joint,

or

tendon

that

caused

you

to

miss

a

practice

or

game?

26.

Are

you

trying

to

or

has

anyone

recom-

15.

Do

you

have

a

bone,

muscle,

ligament,

or

joint

f

5

mended

that

you

gain

or

lose

weight?

injury

that

bothers

you?

ING

QUESTIONS

©

eee

van

|e

=|

|

27.

Are

you

ona

special

diet

or

do

you

avoid

Uae

Pian

oa

—

:

—

certain

types

of

food

and

food

groups?

16.

Do

you

cough,

wheeze,

or

have

difficulty

breathing

during

or

after

exercise?

28.

Have

you

ever

had

an

in

ating

Glsoxsier

17.

Are

you

missing

a

kidney,

an

eye,

a

testicle

pa

psa

ViNeas

NRG

See

(males),

your

spleen,

or

any

other

organ?

29.

Have

you

ever

had

a

menstrual

period?

18.

Do

you

have

groin

or

testicle

pain

or

a

painful

bulge

or

hernia

in

the

groin

area?

30.

How

old

were

you

when

you

had

your

first

menstrual

period?

19.

Do

you

have

any

recurring

skin

rashes

or

rashes

31.

When

was

your

most

recent

menstrual

that

come

and

go,

including

herpes

or

methicillin-

y

iod?

resistant

Staphylococcus

aureus

(MRSA)?

res

:

we

32.

How

many

periods

have

you

had

in

the

past

20.

Have

you

had

a

concussion

or

head

injury

that

12

months?

caused

confusion,

a

prolonged

headache,

or

memory

problems?

Explain

“Yes”

answers

here.

21.

Have

you

ever

had

numbness,

tingling,

B

weakness

in

your

arms

or

legs,

or

been

unable

to

move

your

arms

or

legs

after

being

hit

or

falling?

22.

Have

you

ever

become

ill

while

exercising

in

the

heat?

23.

Do

you

or

does

someone

in

your

family

have

sickde

cell

trait

or

disease?

24,

Have

you

ever

had

or

do

you

have

any

problems

with

your

eyes

or

vision?

[hereby

state

that,

to

the

best

of

my

knowledge,

my

answers

to

the

questions

on

this

form

are

complete

and

correct.

Signature

of

athlete:

Signature

of

parent

or

guardian:

Date:

©

2019

American

Academy

of

Family

Physicians,

American

Academy

of

Pediatrics,

American

College

of

Sports

Medicine,

American

Medical

Society

for

Sports

Medicine,

American

Orthopedic

Society

for

Sports

Medicine,

and

American

Osteopathic

Academy

of

Sports

Medicine.

Permission

is

granted

to

reprint

for

noncommercial,

educational

purposes

with

acknowledgement.

(2

of

5)

PHYSICAL

EXAMINATION

(Physical

examination

must

be

performed

on

or

after

April

1

by

a

health

care

professional

holding

an

unlimited

license

to

practice

medicine,

a

nurse

practitioner

or

a

physician

assistant

to

be

valid

for

the

following

school

year.)

Rule

3-10.

Valid

April

1,

2023-May

31,

2024

Name

Date

of

Birth

Grade

IHSAA

Member

School

PHYSICIAN

REMINDERS

1,

Consider

additional

questions

on

more

sensitive

issues

¢

Do

you

feel

stressed

out

or

under

a

lot

of

pressure?

e

Do

you

ever

feel

sad,

hopeless,

depressed,

or

anxious?

¢

Do

you

feel

safe

at

your

home

or

residence?

°

Have

you

ever

tried

cigarettes,

chewing

tobacco,

snuff,

or

dip?

«

During

the

last

30

days,

did

you

use

chewing

tobacco,

snuff,

or

dip?

¢

Do

you drink

alcohol

or

use

any

other

drugs?

«

Have

you

ever

taken

anabolic

steroids

or

use

any

other

appearance/performance

supplement?

«

Have

you

ever

taken

any

supplements

to

help

you

gain

or

lose

weight

or

improve

your

performance?

¢

Do

you

wear

a

seat

belt,

use

a

helmet, and

use

condoms?

————

2.

Consider

on

cardiovascular

sy

(

5-14)

Height

Weight

[J

Male[7]Female

'

BP

Pulse

Vision

R20/

L20/

Corrected?

Y

N

Appearance

+

Marfan

stigmata

(kyphoscoliosis,

high-arched

palate,

pectus

excavatum,

arachnodactyly,

arm

span

>

height,

hyperlaxity,

myopia,

MVP,

aortic

insuffiency

Eyes/ears/nose/throat

¢

Pupils

equal

e

Hearing

Lymphnodes

Heart

»

Murmurs

(auscultation

standing,

supine,

+/-

Valsalva)

«

Location

of

point

of

maximal

impuluse

(PMI)

Pulses

«

Simultaneous

femoral

and

radial

pulses

Lungs

Abdomen

Genitourinary

(males

only)

Skin

+

HSV,

lesions

suggestive

of

MRSA,

tinea

corporis

Neurologic

Neck

Knee

Back

Leg/ankle

Shoulder/arm

Foot/toes

Elbow/forearm

Functional

Wrist/hand/fingers

»

Duck-walk,

single

leg

hop

[1

Cleared

for

all

sports

without

restriction

[]

Cleared

for

all

sports

without

restriction

with

recommendations

for

further

evaluation

or

treatment

for

[Not

cleared

[[1

Pending

further

evaluation

[1

For

any

sports

Reason

Recommendations

Thave

examined

the

above-named

student

and

completed

the

preparticipation

physical

evaluation.

The

athlete

does

not

present

apparent

clinical

contraindica-

tions

to

practice

and

participate

in

the

sport(s)

as

outlined

above.

A

copy

of

the

physical

exam

is

on

record

in

my

office

and

can

be

made

available

to

the

school

at

the

request

of

the

parents.

If

conditions

arise

after

the

athlete

has

been

cleared

for

participation,

the

physician

may

rescind

the

clearance

until

the

problem

is

resolved

and

the

potential

consequences

are

completely

explained

to

the

athlete

(and

parents/guardians).

Name

of

Health

Care

Professional

(print/type)

Date

-

Address

Phone

License

#

Signature

of

Health

Care

Professional

»

MD,

DO,

PA,

or

NP

(Circle

one)

(3

of

5)

[i

PREPARTICIPATION

PHYSICAL

EVALUATION

I.

A.

“*“*BOTH

parents

MUST

sign

unless

divorced,

widowed

or

CONSENT

&

RELEASE

CERTIFICATE

—

STUDENT

ACKNOWLEDGMENT

AND

RELEASE

CERTIFICATE

.

|

have

read

the

IHSAA

Eligibility

Rules

(next

page

or

on

the

back)

and

know

of

no

reason

why

|

am

not

eligible

to

represent my

school

in

athletic

com-

petition.

.

If

accepted

as

a

representative,

|

agree

to

follow

the

rules

and

abide

by

the

decisions

of

my

school

and

the

IHSAA.

.

[|

know

that

athletic

participation

is

a

privilege.

|

know

of

the

risks

involved

in

athletic

participation,

understand

that

serious

injury,

illness

and

even

death,

is

a

possible

result

of

such

participation,

and

choose

to

accept

such

risks.

|

voluntarily

accept

any

and

all

responsibility

for

my

own

safety

and

welfare

while

participating

in

athletics,

with

full

understanding

of

the

risks

involved,

and

agree

to

release

and

hold

harmless

my

school,

the

schools

involved

and

the

IHSAA

of

and

from

any

and

all

responsibility

and

liability,

including

any

from

their

own

negligence,

for

any

injury,

illness

or

claim

resulting

from

such

athletic

participation

and

agree

to

take

no

legal

action

against

my

school,

the

schools

involved

or

the

IHSAA

because

of

any

accident

or

mishap

involving

my

athletic

participation.

.

|

consent

to

the

exclusive

jurisdiction

and

venue

of

courts

in

Marion

County,

Indiana

for

all

claims

and

disputes

between

and

among

the

IHSAA

and

me,

including

but

not

limited

to

any

claims

or

disputes

involving

injury,

eligibility

or

rule

violation.

.

give

the

IHSAA

and

its

assigns,

licensees

and

legal

representatives

the

irrevocable

right

to

use

my

picture

or

image

and

any

sound

recording

of

me,

in

all

forms

and

media

and

in

all

manners,

for

any

lawful

purposes.

|

HAVE

READ

THIS

CAREFULLY

AND

KNOW

IT

CONTAINS

A

RELEASE

PROVISION.

(to

be

signed

by

student)

Date:

Student

Signature:

(X)

Printed:

PARENT/GUARDIAN/EMANCIPATED

STUDENT

CONSENT,

ACKNOWLEDGMENT

AND

RELEASE

CERTIFICATE

Undersigned,

a

parent

of

a

student,

a

guardian

of

a

student

or

an

emancipated

student,

hereby

gives

consent

for

the

student

to

participation

in

the

following

interschool

sports

not

marked

out:

,

Boys

Sports:

Baseball,

Basketball,

Cross

Country,

Football,

Golf,

Soccer,

Swimming

&

Diving,

Tennis,

Track

&

Field,

Volleyball,

Wrestling.

Girls

Sports:

Basketball,

Cross

Country,

Golf,

Gymnastics,

Soccer,

Softball,

Swimming

&

Diving,

Tennis,

Track

&

Field,

Volleyball,

Wrestling.

Unified

Sports:

Unified

Flag

Football,

Unified

Track

& Field

Undersigned

understands

that

participation

may

necessitate

an

early

dismissal

from

classes.

Undersigned

consents

to

the

disclosure,

by

the

student's

school,

to

the

IHSAA

of

all

requested,

detailed

financial

(athletic

or

otherwise),

scholastic

and

attendance

records

of

such

school

concerning

the

student.

Undersigned

knows

of

and

acknowledges

that

the

student

knows

of

the

risks

involved

in

athletic

participation,

understands

that

serious

injury,

illness

and

even

death,

is

a

possible

result

of

such

participation

and

chooses

to

accept

any

and

all

responsibility

for

the

student’s

safety

and

welfare

while

participating

in

athletics.

With

full

understanding

of

the

risks

involved,

undersigned

releases

and

holds

harmless

the

student’s

school,

the

schools

involved

and

the

IHSAA

of

and

from

any

and

all

responsibility

and

liability,

including

any

from

their

own

negligence,

for

any

injury

or

claim

resulting

from

such

athletic

participation

and

agrees

to

take

no

legal

action

against

the

IHSAA

or

the

schools

involved

because

of

any

accident

or

mishap

involving

the

student’s

athletic

participation.

Undersigned

consents

to

the

exclusive

jurisdiction

and

venue

of

courts

in

Marion

County,

Indiana

for

all

claims

and

disputes

between

and

among

the

IHSAA

and

me

or

the

student,

including

but not

limited

to

any

claims

or

disputes

involving

injury,

eligibility,

or

rule

violation.

Undersigned

gives

the

IHSAA

and

its

assigns,

licensees

and

legal

representatives

the

irrevocable

right

to

use

any

picture

or

image

or

sound

re-

cording

of

the

student

in

all

forms

and

media

and

in

all

manners,

for

any

lawful

purposes.

Please

check

the

appropriate

space:

QC)

The

student

has

adequate

family

insurance

coverage.

UThe

student

does

not

have

insurance

C1

The

student

has

football

insurance

through

school.

Company:

Policy

Number:

|

HAVE

READ

THIS

CAREFULLY

AND

KNOW

IT

CONTAINS

A

RELEASE

PROVISION.

(to

be

completed

and

signed

by

all

parents/guardians,

emancipated

students;

where

divorce

or

separation,

parent

with

legal

custody

must

sign)

Date:

Parent/Guardian/Emancipated

Student

Signature:

(X)

separated,

then

only

custodial

parent/guardian

signs.

Print:

OE

es

Parent/Guardian

Signture:

(X)

Printed:

CONSENT

&

RELEASE

CERTIFICATE

Indiana

High

School

Athletic

Association,

Inc.

9150

North

Meridian

St.,

P.O.

Box

40650

~

Indianapolis,

IN

46240-0650

File

In

Office

of

the

Principal

Separate

Form

Required

for

Each

School

Year

DLC:

3/2/2023

g:/printing/forms/schaols/2023-24PhysicalForm/2023-24

Physical

Form.pdf

(5

of

5)