The Illinois Pre Participation Physical form is a crucial document designed for student-athletes, ensuring their health and safety before they engage in sports activities. This form gathers essential medical history and physical examination details, helping healthcare providers assess any potential risks associated with athletic participation. It is important for parents and athletes to complete this form accurately to promote a safe sporting experience.
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The Illinois Pre Participation Physical form is a crucial document designed to ensure the health and safety of student-athletes before they engage in sports activities. This form requires input from both the athlete and their parent or guardian and must be completed prior to the physical examination. It collects essential information such as the athlete's personal details, medical history, and any current medications or allergies. The form includes a series of questions that address general health, heart health, bone and joint issues, and other medical concerns that may impact the athlete's ability to participate safely in sports. Specific sections inquire about past injuries, family medical history, and any ongoing health conditions that could pose risks during athletic activities. The physical examination section assesses various health indicators, including height, weight, blood pressure, and overall physical condition. Additionally, there is a consent section for high school students regarding performance-enhancing substances, highlighting the commitment to fair play and health in sports. This comprehensive approach aims to identify potential health risks and ensure that all student-athletes are fit to compete.
Illinois Standard Deduction 2023 - The thoroughness of the form helps ensure no detail regarding assets or liabilities is overlooked.
When considering important legal documents, individuals in Texas should not overlook the relevance of the Texas Durable Power of Attorney form. This essential instrument allows designated agents to manage a person’s financial and legal matters, particularly in situations where the principal may become incapacitated. For detailed resources and templates related to this topic, visit TopTemplates.info, which provides valuable information on the significance of planning for one's future.
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Misconceptions about the Illinois Pre Participation Physical form can lead to confusion for athletes and their families. Here are seven common misunderstandings:
Understanding these misconceptions can help ensure a smoother process for athletes and their families as they prepare for 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
When filling out the Illinois Pre Participation Physical form, there are important guidelines to follow. Here are four things you should and shouldn't do:
Completing the Illinois Pre Participation Physical form is an important step in ensuring that student-athletes are ready for participation in sports. This form gathers essential health information that will help medical professionals assess the athlete's readiness for physical activity. Follow the steps outlined below to fill out the form accurately.
Once the form is completed, it should be submitted to the appropriate school authority or medical professional for review. This step is crucial for ensuring that the athlete is cleared for participation in sports activities.