Physical Evaluation Form

DOB: 

Date of examination: 

Sex assigned at birth (F, M, or intersex):  F  M  Intersex

How do you identify your gender? (F, M, or other):   F  M  Other

Have you ever had surgery?

 Yes  No 

Do you have any allergies?

 Yes  No 

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

 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 > 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?
 Yes  No 
Has a provider ever denied or restricted your participation in sports for any reason?
 Yes  No 
Do you have any ongoing medical issues or recent illness?
 Yes  No 
Have, you ever passed out or nearly passed out during or after exercise?
 Yes  No 
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
 Yes  No 
Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
 Yes  No 
Has a doctor ever told you that you have any heart problems? 
 Yes  No 
Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG)
 Yes  No 

Do you get light-headed or feel shorter of breath than your friends during exercise?  
 Yes  No 
Have you ever had a seizure? 
 Yes  No 
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)? 
 Yes  No 
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)? 
 Yes  No 
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?  
 Yes  No 
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? 
 Yes  No 
Do you have a bone, muscle, ligament, or joint injury that bothers you? 
 Yes  No 

Do you cough, wheeze, or have difficulty breathing during or after exercise? 
 Yes  No 
Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? 
 Yes  No 
Do you have groin or testicle pain or a painful bulge or hernia in the groin area? 
 Yes  No 
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus 
(MRSA)? 
 Yes  No 
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? 
 Yes  No 
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?
 Yes  No 
Have you ever become ill after exercising in the heat?
 Yes  No 
Do you or does someone in your family have sickle cell trait or disease?
 Yes  No 
Have you ever had or do you have any problems with your eyes or vision?
 Yes  No 

Do you worry about your weight? 
 Yes  No 
Are you trying to or has anyone recommended that you gain or lose weight?
 Yes  No 
Are you on a special diet or do you avoid certain types of foods or food groups?
 Yes  No 
Have you ever had an eating disorder?
 Yes  No 
Female Only Questions
Have you ever had a menstrual period? 
 Yes  No 
How old were you when you had your first menstrual period?
 Yes  No 
When was your most recent menstrual period?
 Yes  No 
How many periods have you had in the past 12 months?
 Yes  No 
 

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: 

Date: