TeamSafe®Sports Sports Physical: Preparticipation Physical Evaluation History Form
Public high school sports programs typically require that athletes have a pre-season "sports physical." What about prior to league or club sports? Please complete the American Academy of Pediatrics Preparticipation Physical Evaluation History form? It has over 30 questions and is very important!

Source: https://www.aap.org/en-us/Documents/PPE-History-Form-%28English%29.pdf
The 2019 form has removed several previously asked questions. We have kept these as part of this form and removed the number from the question. We feel all the questions removed still hold importance and value to you the athlete and parent.

Read this too! https://www.shapeamerica.org/uploads/pdfs/PhysicalLiteracy_AspenInstitute-FINAL.pdf
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List past and current medical conditions
Have you ever had surgery?
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If you have had surgery list all past surgical procedures
Medications and supplements. List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional)
Do you have any allergies?
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If you have allergies, please list all your allergies (i.e., medicines, pollens, food, stinging insects)
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious, or on edge
0 = not at all
1 = Several days
2 = Over half the days
3 = Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
General Questions
Please explain any yes answers at the end of this form
1. Do you have any concerns that you would like to discuss with your provider?
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2. Has a doctor ever denied or restricted your participation in sports for any reason? *
3. Do you have any ongoing medical issues or recent illness?
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Have you ever spent the night in the hospital? *
HEART HEALTH QUESTIONS ABOUT YOU
Please see this link for video explanations of heart related questions: https://my.studytrax.com/p/sports/portal/index#/accounts/enroll
4. Have you ever passed out or nearly passed out DURING or AFTER exercise? *
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? *
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? *
7. Has a doctor ever told you that you have any heart problems? *
If so, check all that apply:
8. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,echocardiogram) *
9. Do you get lightheaded or feel more short of breath than expected during exercise? *
10. Have you ever had a seizure? *
Do you get more tired or short of breath more quickly than your friends during exercise? *
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
11. 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)? *
12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)? *
13. Does anyone in your family had a pacemaker or implanted defibrillator before age 35? *
Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
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BONE AND JOINT QUESTIONS
14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game? *
15. Do you have a bone, muscle, or joint injury that bothers you? *
Have you ever had any broken or fractured bones or dislocated joints? *
Have you ever had an injury that required x-rays, MRI, CT scan,injections, therapy, a brace, a cast, or crutches? *
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) *
Do you regularly use a brace, orthotics, or other assistive device? *
Do any of your joints become painful, swollen, feel warm, or look red? *
Do you have any history of juvenile arthritis or connective tissue disease? *
MEDICAL QUESTIONS
16. Do you cough, wheeze, or have difficulty breathing during or after exercise? *
17. Were you born without or are you missing a kidney, an eye, a testicle(males), your spleen, or any other organ? *
18. Do you have groin pain or testicle pain or a painful bulge or hernia in the groin area? *
19. Do you have any recurring rashes or rashes that come and go, including herpes or methicillen-resistant Staphylococcus aureus (MRSA)? *
Have you had infectious mononucleosis (mono) within the last month? *
20. Have you ever had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? *
21. Have you ever had numbness, tingling, or weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling? *
Do you have a history of seizure disorder? *
Do you have headaches with exercise? *
22. Have you ever become ill while exercising in the heat? *
Do you get frequent muscle cramps when exercising? *
23. Do you or someone in your family have sickle cell trait or disease? *
24. Do you have or have you had any problems with your eyes or vision? *
Have you had any eye injuries? *
Do you wear glasses or contact lenses? *
Do you wear protective eye wear, such as goggles or a face shield? *
25. Do you worry about your weight? *
26. Are you trying to or has anyone recommended that you gain or lose weight? *
27. Are you on a special diet or do you avoid certain types of foods? *
28. Have you ever had an eating disorder? *
Have you ever used an inhaler or taken asthma medicine? *
Is there anyone in your family who has asthma? *
FEMALES ONLY
52. Have you ever had a menstrual period? *
53. How old were you when you had your first menstrual period? *
54. How many periods have you had in the last 12 months? *
Please explain any yes answers and add any comments and/or questions
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