Texas Pre-Participation Physical Evaluation - Medical History Both Parent and Student Must Fill Out This Form Together
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
By clicking the "Agree and Submit Form" button below you are stating the information on this form is true and correct. You are also agreeing as the parent/guardian and student/team member to abide by all applicable rules and regulations related to participating as either a parent/guardian and student/team member of the sports program.
As the parent or gardian you are concenting for the below named student to participate in activities, you understand the risk of injury in athletic participation, and if the below named student becomes ill or is injured, necessary medical care can be instituted by Physician, Athletic Trainer, Coaches or other personnel properly trained.
After submitting the form you will receive a confirmation page which you can print for your records. Team Member Information
1.Have you ever had a medical illness or injury since last checkup or sports physical?No
2. Have you ever been hospitalized overnight in the Nopast year?
3. Have you ever passed out during or after
3a. Have you ever had chest pain during or after
3b. Do you get tired more quickly than your friends Nodo during exercise?
3c. Have you ever had racing of your heart or
3d. Have you had high blood pressure or high
3e. Have you ever been told you have a heart
3f. Has any family member or relative died of heart Noproblems or of sudden death before the age of 50?
3g. Has any family member been diagnosed with enlarged heart, hypertrophic cardiomyopathy, long QT syndrome, Marfan's syndrome, or abnormal heart rhythm?No
3h. Have you had a severe viral infection (I. E.
mononucleosis or myocarditis) within the last month?
3i. Has a physician ever denied or restricted your participation in sports for any heart problems?No
4. Have you ever had a head injury or concussion?
4a. Have you ever been knocked out, become unconscious or lost your memory?
4a1. If yes, how many times?4a2 When was the last concussion? Enter numbers only or use calendar to the right. November 15, 1952 would be entered as 19521115.
4c. Do you have frequent or severe headaches?
4d. Have you ever had numbness or tingling in your arms, hands, legs or feet?
4e. Have you ever had a stinger, burner, or pinched nerve?
7. Are you currently taking any prescription or non-prescription (over-the-counter) medication or pills or using an inhaler?
8. Do you have any allergies (I. E. Pollen, medicine, Yesfood or stinging insects)?
9. Have you ever been dizzy during or after
10. Do you have any current skin problems (for
example, itching, rashes, acne, warts, fungus, or blisters)?
11. Have you ever become ill from exercising in the Noheat?
12. Have you had any problems with your eyes or
13. Have you ever gotten unexpectedly short of
13b. Do you have seasonal allergies that require
14. Do you use any special protective for corrective equipment or devices that are usually used for your sport or precision (I. E.knee brace, special neck roll, foot orthotics, retainer for your teeth or hearing aid)?Yes
15. Have you ever had a sprain, strain or swelling after injury?
15a. Have you broken or fractured any bones or dislocated any joints?
16. Do you want to weigh more or less than you do now?
16a. Do you lose weight regularly or meet weight requirements for your sport?
18. Have you ever been diagnosed with or treated for sickle cell trait or sickle cell disease?
Explain any answers you answered "Yes" to below:
8) Allergies: Amoxycillin, Omnicef14) Contact Lenses. 15) Left Ankle sprain 3/2012 full recovery. The Following Questions are for Females Only
19. When was your first menstrual period? Enter numbers only or use calendar to the right. November 15, 1952 would be entered as 19521115. 2013031219a. When was your most recent menstrual period? Enter numbers only or use calendar to the right. November 15, 1952 would be entered as 19521115. 20130312
List the sports studeny will be participating in:
Beginning with the 2002-2003 sports seasons, all athletic participants will be required to obtain a yearly physical examination prior to participation in games, practices, try-outs, workouts (in-season or out-of- season). The physical examination is to be completed by either a Physician as licensed by the Texas Medical Examiners Board (M.D. or D.O.), a Physician Assistant licensed by a State Board of Physician Assistant Examiners, or a Registered Nurse recognized as an Advanced Practice Nurse by the Board of Nurse Examiners. Also, the Athletic Participation, UIL Rules, Medical History, Steroid Use/Testing forms and Emergency Information Card are to be completed and on file yearly prior to participation in games, practices, try-outs, and workouts (in-season or out-of-season). Including all Athletic Periods
19b. How much time do you usually have from the start of one period to the start of another? 30 days
19d. How many periods have you had this last year?
19e. What was the longest time between periods in the last year?
An individual answering in the affirmative to any question relating to a possible cardiovascular health issue (question three above), as identified on the form, should be restricted from further participation until the individual is examined and cleared by a physician, physician assistant, chiropractor, or nurse practitioner. It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither the University Interscholastic League nor the school assumes any responsibility in case an accident occurs.If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, athletic trainer, nurse or school representative. I do hereby agree to indemnify and save harmless the school and any school or hospital representative from any claim by any person on account of such care and treatment of said student.If, between this date and the beginning of athletic competition, any illness ore injury should occur that may limit this student's participation, I agree to notify the school authorities of such illness or injury.I, the student named above, hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL. I, the parent named above, hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Failure to provide truthful responses could subject the student in question to penalties determined by the UIL.
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