display/hide demographics
Name:
Date of Birth:

display/hide history sectionhistory questionnaire for athlete or guardian to complete separately

HISTORY
<-- 1. Has anyone in the athlete’s family died suddenly before the age of 50 years?
<-- 2. Has the athlete ever passed out during exercise or stopped exercising because of dizziness or chest pain?
<-- 3. Does the athlete have asthma (wheezing), hay fever, other allergies, or carry an EPI pen?
<-- 4. Is the athlete allergic to any medications or bee stings?
<-- 5. Has the athlete ever broken a bone, had to wear a cast, or had an injury to any joint?
<-- 6. Has the athlete ever had a head injury or concussion?
<-- 7. Has the athlete ever had a hit or blow to the head that caused confusion, memory problems, or prolonged headache?
<-- 8. Has the athlete ever suffered a heat‐related illness (heat stroke)?
<-- 9. Does the athlete have a chronic illness or see a physician regularly for any particular problem?
<-- 10. Does the athlete take any prescribed medicine, herbs or nutritional supplements?
<-- 11. Does the athlete have only one of any paired organ (eyes, kidneys, testicles, ovaries, etc.)?
<-- 12. Has the athlete ever had prior limitation from sports participation?
<-- 13. Has the athlete had any episodes of shortness of breath, palpitations, history of rheumatic fever or tiring easily?
<-- 14. Has the athlete ever been diagnosed with a heart murmur or heart condition or hypertension?
<-- 15. Is there a history of young people in the athlete’s family who have had heart disease: examples are cardiomyopathy, abnormal heart rhythms, long QT or Marfan's syndrome?
<-- 16. Has the athlete ever been hospitalized overnight or had surgery?
<-- 17. Does the athlete lose weight regularly to meet the requirements for your sport?
<-- 18. Does the athlete have anything he or she wants to discuss with the physician?
<-- 19. Does the athlete cough, wheeze, or have trouble breathing during or after activity?
<-- 20. Is the athlete unhappy with his or her weight?


EXAMINATION
display/hide vitals section
VITALS
Weight: lbs
Height: inches
BMI: calculated - will display in outputscore=((wt)*(703)/((ht)*(ht))).toFixed(1)
Blood Pressure:
Heart Rate:
display/hide vision section
VISION
Right 20/ - Left 20/ -
<-- Appearance
<-- Eyes / Ears / Nose / Throat
<-- Lymph Nodes
<-- Heart
<-- Lungs
<-- Abdomen
<-- Skin
MUSCULOSKELETAL
<-- Stand facing examiner (check AC joints, general habitus)
<-- Look at ceiling, floor, over shoulders, touch ears to shoulders (check cervical spine motion)
<-- Shrug shoulders against resistance (check trapezius strength)
<-- Abduct shoulders 90 degrees, hold against resistance (check deltoid strength)
<-- Externally rotate arms fully (check shoulder motion)
<-- Flex and extend elbows (check elbow motion)
<-- Arms at sides, elbows 90 degrees flexed, pronate/supinate wrists
<-- Spread fingers, make fist (check elbow and wrist motion)
<-- Contract quadriceps, relax quadriceps (check symmetry and knee/ankle effusion)
<-- “Duck walk” 4 steps away from examiner (check hip, knee and ankle motion)
<-- Stand with back to examiner (check scoliosis)
<-- Knees straight, touch toes (check scoliosis, hip motion, hamstrings)
<-- Rise up on heels, then toes (check calf symmetry, leg strength)

ASSESSMENT:


RECOMMENDATIONS:


display/hide references
Reference: #1 Mirabelli MH, Devine MJ, Singh J, Mendoza M. The Preparticipation Sports Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-6.

Result - Copy and paste this output: