The Illinois Pre Participation Physical form is a document that must be completed by student-athletes or their parents before participating in sports. This form gathers essential health information, including medical history and current health status, to ensure the safety of the athlete. It is important to fill out this form accurately and completely; click the button below to get started.
The Illinois Pre Participation Physical form plays a crucial role in ensuring the safety and well-being of student-athletes participating in sports. Before any examination, this form must be filled out by either the athlete or their parent. It collects essential information, such as the athlete's name, contact details, birth date, and medical history. The form includes sections that inquire about medications, allergies, and any past medical conditions that could affect athletic performance. Specific questions address heart health, bone and joint injuries, and other medical concerns, allowing healthcare providers to assess potential risks. Additionally, there are sections dedicated to female athletes, addressing menstrual history, which is important for understanding their overall health. The physical examination portion of the form evaluates various aspects of the athlete's health, including height, weight, and heart function. Finally, it includes a consent section for random steroid testing, emphasizing the commitment to fair play and athlete integrity. This comprehensive approach aims to safeguard the health of student-athletes while promoting a culture of safety in sports participation.
Pre-participation Examination
To be completed by athlete or parent prior to examination.
Name
School Year
Last
First
Middle
Address
City/State
Phone No.
Birthdate
Age
Class
Student ID No.
Pare t’s Na e
HISTORY FORM
Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies?
Yes
No
If yes, please identify specific allergy below.
Medicines
Pollens
Food
Stinging Insects
E plain Yes answe s elow. Ci
le uestions ou don’t know the answe s to.
GENERAL QUESTIONS
Yes
No
1.
Has a doctor ever denied or restricted your participation in sports
for any reason?
2.
Do you have any ongoing medical conditions? If so, please identify
below: Asthma Anemia Diabetes Infections
Other: _
__________
3.
Have you ever spent the night in the hospital?
4.
Have you ever had surgery?
HEART HEALTH QUESTIONS ABOUT YOU
5.
Have you ever passed out or nearly passed out DURING or AFTER
exercise?
6.
Have you ever had discomfort, pain, tightness, or pressure in your
chest during exercise?
7.
Does your heart ever race or skip beats (irregular beats) during
8.
Has a doctor ever told you that you have any heart problems? If
so, check all that apply: High blood pressure A heart murmur
High cholesterol A heart infection Kawasaki disease
Other: ___
______
9.
Has a doctor ever ordered a test for your heart? (For example,
ECG/EKG, echocardiogram)
10.
Do you get lightheaded or feel more short of breath than
expected during exercise?
11.
Have you ever had an unexplained seizure?
12.
Do you get more tired or short of breath more quickly than your
friends during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
13.
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)?
14.
Does anyone in your family have hypertrophic cardiomyopathy,
Marfan syndrome, arrhythmogenic right ventricular
cardiomyopathy, long QT syndrome, short QT syndrome, Brugada
syndrome, or catecholaminergic polymorphic ventricular
tachycardia?
15.
Does anyone in your family have a heart problem, pacemaker, or
implanted defibrillator?
16.
Has anyone in your family had unexplained fainting, unexplained
seizures, or near drowning?
BONE AND JOINT QUESTIONS
17.
Have you ever had an injury to a bone, muscle, ligament, or
tendon that caused you to miss a practice or a game?
18.
Have you ever had any broken or fractured bones or dislocated
joints?
19.
Have you ever had an injury that required x-rays, MRI, CT scan,
injections, therapy, a brace, a cast, or crutches?
20.
Have you ever had a stress fracture?
21.
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)
22.
Do you regularly use a brace, orthotics, or other assistive device?
23.
Do you have a bone, muscle, or joint injury that bothers you?
24.
Do any of your joints become painful, swollen, feel warm, or look
red?
25.
Do you have any history of juvenile arthritis or connective tissue
disease?
MEDICAL QUESTIONS
26.Do you cough, wheeze, or have difficulty breathing during or after exercise?
27.
Have you ever used an inhaler or taken asthma medicine?
28.
Is there anyone in your family who has asthma?
29.
Were you born without or are you missing a kidney, an eye, a
testicle (males), your spleen, or any other organ?
30.
Do you have groin pain or a painful bulge or hernia in the groin
area?
31.
Have you had infectious mononucleosis (mono) within the last
month?
32.
Do you have any rashes, pressure sores, or other skin problems?
33.
Have you had a herpes or MRSA skin infection?
34.
Have you ever had a head injury or concussion?
35.
Have you ever had a hit or blow to the head that caused
confusion, prolonged headache, or memory problems?
36.
Do you have a history of seizure disorder?
37.
Do you have headaches with exercise?
38.
Have you ever had numbness, tingling, or weakness in your arms
or legs after being hit or falling?
39.
Have you ever been unable to move your arms or legs after being
hit or falling?
40.
Have you ever become ill while exercising in the heat?
41.
Do you get frequent muscle cramps when exercising?
42.
Do you or someone in your family have sickle cell trait or disease?
43.
Have you had any problems with your eyes or vision?
44.
Have you had any eye injuries?
45.
Do you wear glasses or contact lenses?
46.
Do you wear protective eyewear, such as goggles or a face shield?
47.
Do you worry about your weight?
48.
Are you trying to or has anyone recommended that you gain or
lose weight?
49.
Are you on a special diet or do you avoid certain types of foods?
50.
Have you ever had an eating disorder?
51.
Have you or any family member or relative been diagnosed with
cancer?
52.
Do you have any concerns that you would like to discuss with a
doctor?
FEMALES ONLY
53.
Have you ever had a menstrual period?
54.How old were you when you had your first menstrual period?
55.How many periods have you had in the last 12 months?
Explain es answe s he e
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete
Signature of parent/guardian
Date
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503
PHYSICAL EXAMINATION FORM
EXAMINATION
Height
Weight
Male
Female
BP
/
(
)
Pulse
Vision R 20/
L 20/
Corrected
Y N
MEDICAL
NORMAL
ABNORMAL FINDINGS
Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum,
arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/ears/nose/throat
Pupils equal
Hearing
Lymph nodes
Heart a
Murmurs (auscultation standing, supine, +/- Valsalva)
Location of point of maximal impulse (PMI)
Pulses
Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)b
Skin
HSV, lesions suggestive of MRSA, tinea corporis
Neurologic c
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/Ankle
Foot/toes
Functional
Duck-walk, single leg hop
aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.
bConsider GU exam if in private setting. Having third party present is recommended.
cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
O the
asis of the e a i
atio
o this da
, I appro e this
hild’s parti ipatio i
i ters holasti
sports for o
e year.
Limited
Examination Date
Additional Comments:
Ph
si ia
’s Sig ature
’s Assista t Sig ature*
Ad a ed Nurse Pra titio er’s Sig ature*
*effective January 2003, the IHSA Board of Dire tors appro ed a re o
e datio , o siste t ith the Illi ois S hool Code, that allo s Ph si ia ’s Assista ts or
Advanced Nurse Practitioners to sign off on physicals.
IHSA Steroid Testing Policy Consent to Random Testing
(This section for high school students only)
2011-2012 school term
As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school
day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student’s high school as specified in the IHSA
Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student to penalties as determined by IHSA.
A complete list of the current IHSA Banned Substance Classes can be accessed at
http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes.pdf
Signature of student-athlete
Signature of parent-guardian
Filling out the Illinois Pre Participation Physical form is a crucial step for athletes before they can participate in sports. This form collects important health information that will help ensure the safety of the student during athletic activities. It is essential to provide accurate and complete answers to all questions. Once the form is filled out, it must be signed by both the athlete and a parent or guardian.
The Illinois Pre Participation Physical form is designed to assess an athlete's health and readiness to participate in sports. It collects vital information regarding the athlete's medical history, current medications, allergies, and any ongoing medical conditions. This ensures that any potential health risks are identified before participation, promoting safety and well-being during athletic activities.
All student-athletes participating in interscholastic sports in Illinois are required to complete the Illinois Pre Participation Physical form. This includes students at both high school and middle school levels. Parents or guardians must assist younger athletes in filling out the form, ensuring that all information is accurate and complete. Without this form, students may not be allowed to participate in sports.
The form requires several key pieces of information, including:
Completing all sections thoroughly is crucial for ensuring a comprehensive health evaluation.
The Illinois Pre Participation Physical form must be updated annually. Each year, athletes should undergo a new physical examination to ensure their health status has not changed. This is particularly important for identifying any new medical conditions or changes in health that could affect athletic participation. Parents and guardians should keep track of the expiration date of the form to ensure compliance with school policies.
Failing to provide complete contact information for both the athlete and the parent or guardian. This includes missing phone numbers or addresses.
Not listing all medications and allergies. It's crucial to include every prescription and over-the-counter medicine, as well as any known allergies.
Leaving medical history questions unanswered. If unsure about a question, it's better to circle it and discuss it with the doctor rather than skipping it.
Not checking the heart health questions thoroughly. Many athletes may overlook symptoms like chest pain or irregular heartbeats.
Failing to disclose family medical history related to heart problems. This can be crucial for understanding potential risks.
Omitting details about any previous injuries. This includes not mentioning past surgeries or any ongoing issues with bones or joints.
Not indicating if the athlete has ever experienced concussions or head injuries. This information is vital for ensuring safety during sports.
Overlooking the female-specific questions if applicable. It's important for female athletes to provide this information accurately.
Not signing and dating the form. Both the athlete and parent or guardian must provide their signatures for the form to be valid.
Submitting the form without reviewing it for accuracy. It's essential to double-check all answers to ensure they are correct and complete.
When preparing for participation in sports, the Illinois Pre Participation Physical form is just one of several important documents. These forms help ensure that athletes are healthy and ready to engage in physical activities. Here are a few other forms and documents that are commonly used alongside the Pre Participation Physical form:
Each of these documents plays a vital role in safeguarding the health and well-being of young athletes. By completing them thoroughly, parents and guardians can help ensure that their children are well-prepared for a safe and enjoyable sports experience.
The Illinois Pre Participation Physical form is similar to the Sports Physical Examination form used in many states. Both documents require athletes to provide personal information, including their medical history and any existing health conditions. They aim to ensure that the athlete is physically fit to participate in sports and identify any potential health risks. The focus on heart health and injury history is common in both forms, ensuring that athletes are not at risk during their activities.
Another document similar to the Illinois Pre Participation Physical form is the NCAA Sports Medical Examination form. This form is specifically for college athletes and includes sections on medical history, physical examination findings, and any previous injuries. Like the Illinois form, it emphasizes the importance of understanding an athlete's health background before allowing them to compete. Both forms serve to protect athletes by ensuring they are cleared for participation based on their health status.
The AHA Preparticipation Physical Evaluation (PPE) form is also comparable. This document is endorsed by the American Heart Association and focuses heavily on cardiovascular health. It asks questions about family history of heart issues and requires a thorough physical examination. Similar to the Illinois form, it aims to identify any potential heart problems that could put athletes at risk during physical activity.
The California Preparticipation Physical Evaluation form shares similarities with the Illinois form as well. It requires detailed medical history and physical examination results. Both forms include questions about past injuries, chronic conditions, and family medical history. The goal is to ensure that athletes are healthy enough to engage in sports, minimizing the risk of serious health issues.
The Texas Preparticipation Physical Evaluation form is another document that aligns closely with the Illinois version. It includes sections for medical history, physical examination, and clearance for participation. Both forms prioritize the athlete's safety by requiring a comprehensive review of their health before they can compete in sports.
The Florida High School Athletic Association (FHSAA) Preparticipation Physical Evaluation form is also similar. It collects information about the athlete's medical history, current medications, and any allergies. Both forms aim to assess the athlete's readiness for sports participation and identify any potential health concerns that need to be addressed before they take the field.
Lastly, the Michigan High School Athletic Association (MHSAA) Sports Physical form is comparable to the Illinois Pre Participation Physical form. It gathers information about the athlete's health history and includes a physical examination section. Both forms serve the same purpose: to ensure that athletes are physically fit and to identify any health issues that may affect their ability to safely participate in sports.
Completing the Illinois Pre Participation Physical form accurately is crucial for ensuring the health and safety of student-athletes. Below is a list of important do's and don'ts to consider when filling out this form.
By following these guidelines, you can help ensure that the athlete is adequately prepared for their physical examination and subsequent participation in sports.
This is incorrect. The Illinois Pre Participation Physical form is designed for all student-athletes, regardless of their health status. It aims to ensure that every athlete is fit to participate in sports and to identify any potential health concerns before they begin.
While parents play a crucial role in providing information, the form requires input from the student-athlete as well. Athletes should be involved in discussing their medical history and current health status to ensure accurate information is reported.
This is a misunderstanding. A physical examination is mandatory for participation in school sports. It serves as a precautionary measure to identify any underlying health issues that may not be immediately apparent.
Submitting the form does not automatically ensure that an athlete will be cleared for participation. The final decision rests with the examining physician, who evaluates the athlete's health based on the examination results and medical history.
This is misleading. The form covers a wide range of health topics, including mental health and family medical history. Understanding the athlete's complete health profile is essential for their safety in sports.
While school physicians are common, other qualified healthcare providers, such as nurse practitioners and physician assistants, are also authorized to conduct the examination. This flexibility allows for better accessibility for families.
When filling out and using the Illinois Pre Participation Physical form, there are several important points to keep in mind. This form is essential for ensuring that student-athletes are healthy enough to participate in sports. Here are some key takeaways:
Completing the Illinois Pre Participation Physical form thoroughly and accurately is essential for the safety and well-being of student-athletes. Proper attention to detail can help prevent health issues during sports activities.