AHSAA-Physical-Evaluation-Form-1.pdf

ALABAMAHIGHSCHOOLATHLETICASSOCIATION

Name__________________________________________________Sex________ Age______ Dateof birth___________

____

Address_____________________________________________________________________

_ Phone______________________

School________________________________________________________Grade__________Sport______________________

PreparticipationPhysicalEvaluation Form

Revised 2018

History Date_______________________

Explain“Yes”answersbelow: Yes No

1. Hasadoctoreverrestricted/deniedyourparticipationinsports?

2. Haveyoueverbeenhospitalizedorspentanightinahospital?

Haveeverhadsurgery?

3. Doyouhaveanyongoingmedicalconditions(likeDiabetesorAsthma)?

4. Areyoupresentlytakinganymedicationsorpills(prescriptionorover‐the‐counter?

5. Doyouhaveanyallergies(medicine,pollens,foods,beesorotherstinginginsects)?

6. Haveyoueverpassedoutduringorafterexercise?

Haveyoueverbeendizzyduringorafterexercise?

Haveyoueverhadchestpainordiscomfortinyourchestduringorafterexercise?

Doyoutiremorequicklythanyourfriendsduringexercise?

Haveyoueverhadhighbloodpressure?

Haveyoueverbeentoldthatyouhaveaheartmurmur,highcholesterol,orheartinfection?

Haveyoueverhadracingofyourheartorskippedheartbeats?

Hasanyoneinyourfamilydiedofheartproblemsorasuddendeathbeforeage50?

Doesanyoneinyourfamilyhaveaheartcondition?

Hasadoctoreverorderedatestonyourheart(EKG,echocardiogram)?

7. Doyouhaveanyskinproblems(itching,rashes,staph,MRSA,acne)?

8. Haveyoueverhadaheadinjuryorconcussion?

Haveyoueverbeenknockedoutorunconscious?

Haveyoueverhadaseizure?

Haveyoueverhadastinger,burner,pinchednerve,orlossoffeelingorweaknessinyourarmsorlegs?

9. Haveyoueverhadheatormusclecramps?

Haveyoueverbeendizzyorpassedoutintheheat?

10. Doyouhavetroublebreathingordoyoucoughduringorafteractivity?

Doyoutakeanymedicationsforasthma(forinstance,inhalers)?

11. Doyouuseanyspecialequipment(pads,braces,neckrolls,mouthguard,eyeguards,etc.)?

12. Haveyouhadanyproblemswithyoureyesorvision?

Doyouwearglassesorcontactsorprotectiveeyewear?

13. Haveyouhadanyothermedicalproblems(infectiousmononucleosis,diabetes,infectiousdiseases,etc.)?

14. Haveyouhadamedicalproblemorinjurysinceyourlastevaluation?

15. Haveyoueverbeentoldyouhavesicklecelltrait?

Hasanyoneinyourfamilyhadsicklecelldiseaseorsicklecelltrait?

16. Haveyoueversprained/strained,dislocated,fractured,brokenorhadrepeatedswellingorother

injuriesofanybonesorjoints?

HeadBackShoulderForearmHandHipKneeAnkle

NeckChestElbowWristFingerThighShinFoot

17. Whenwasyourfirstmenstrualperiod?__________________________________________________________________

Whenwasyourlastmenstrualperiod?___________________________________________________________________

Whatwasthelongesttimebetweenyourperiodslastyear?________________________________________________

Explain“Yes”answers:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Iherebystatethat,tothebestofmyknowledge,myanswerstotheabovequestionsarecorrect.

Signatureofathlete___________________________________________________________Date___________________

Signatureofparent/guardian__________________________________________________  DUPLICATEASNEEDED 

Rev. 2018 (The revised 2018 form is the official form accepted by the AHSAA.)

FORM5

Page 1 of 2

Revised 2018

Preparticipation Physical Evaluation

Physical Examination

Rule1,Sec.14 — Inorderforastudenttobeeligibleforinterscholasticathletics,theremustbe

onfilein theSuperintendent’sorPrincipal’sofficeacurrentphysician’sstatementcertifyingthat

thestudenthaspassedaphysicalexam,andthatintheopinionoftheexaminingphysician(M.D.

orD.O.)thestudentisfullyabletoparticipateininterscholasticathletics(Grade s7‐12).The

AHSAAPhysiciansCertificate(Form5 Rev. 2018)mustbeused. Aphysicalexamwillsatisfythe

requirement for one calendar year through the end of the month from the date of the exam. For

example, a physical given on May 5, 2019, will satisfy the requirement through May 31, 2020.

Clearance:

A. Cleared

B. Cleared after completing evaluation/rehabilitation for: _______________________________________

C. Not cleared for:

Collision

Contact

Noncontact ____ Strenuous ____ Moderately strenuous ____ Nonstrenuous

Due to: ____________________________________________________________________________________________

Recommendation: _________________________________________________________________________________________

________________________________________________________________________________________________________

Name of physician ________________________________________________________________ Date ____________________

Address ________________________________________________________________________ Phone___________________

Signature of physician _____________________________________________________________, M.D. or D.O.

LIMITED

Height ____________ Weight _____________ BP _____ / _____ Pulse ____________

Vision R 20 / ____ L 20 / ____ Corrected: Y N

Normal Abnormal Findings

Cardiovascular

Pulses

Heart

Lungs

Skin

E.N.T.

Abdominal

Genitalia (males)

Musculoskeletal

Neck

Shoulder

Elbow

Wrist

Hand

Back

Knee

Ankle

Foot

Other

(Form must be signed and dated by the attending physician.)

Rev. 2018 (The revised 2018 form is the official form accepted by the AHSAA.)

__________________________________________

Student's name

Revised 2018

COMPLETE