Physical Evaluation Form

Note: Complete and sign this form {with your parents if younger than 18) before your appointment.
Date of examination: 
Sex assigned at birth (F, M, or intersex): 
How do you identify your gender? (F, M, or other): 

Have you ever had surgery?

Do you have any allergies?

Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? ( checkbox next to appropriate number)

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

(A sum of > 3 is considered positive on either subscale [questions l and 2, or questions 3 and 4] for screening purposes.)

Medical Questions

Do you have any concerns that you would like to discuss with your provider?

Has a provider ever denied or restricted your participation in sports for any reason?

Do you have any ongoing medical issues or recent illness?

Have, you ever passed out or nearly passed out during or after exercise?

Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?

Has a doctor ever told you that you have any heart problems? 

Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG)
Do you get light-headed or feel shorter of breath than your friends during exercise?  

Have you ever had a seizure? 

Has any family member or relative died of heart problems or had on unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)? 

Does anyone in your family have a genetic heart problem such as hypertrophic cordiomyopothy □ (HCM), Morfon syndrome, arrhythmogenic right ventricular cardiomyopathy (ARV(), long QT syndrome (LQTS), short QT syndrome {SQTS), Brugodo syndrome, or catecholominergic poly-morphic ventricular tachycardia (CPVT)? 

Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?  

Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game? 

Do you have a bone, muscle, ligament, or joint injury that bothers you? 
Do you cough, wheeze, or have difficulty breathing during or after exercise? 

Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 

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

Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus 

Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? 

Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms after being hit or falling?

Have you ever become ill after exercising in the heat?

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

Have you ever had or do you have any problems with your eyes or vision?
Do you worry about your weight? 

Are you trying to or has anyone recommended that you gain or lose weight?

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

Have you ever had an eating disorder?

Female Only Questions
Have you ever had a menstrual period? 

How old were you when you had your first menstrual period?

When was your most recent menstrual period?

How many periods have you had in the past 12 months?


Explain "Yes" Answers Here

I 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: