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Form 5 - 1W-10-10-10-10 ALABAMA HIGH SCHOOL ATHLETIC ASSOCIATION Preparticipation Physical Evaluation History Date __________________ Name ________________________________________ Sex ________ Age_______ Date of birth _____________ Address _______________________________________________________________Phone __________________ School ________________________________________Grade _____________ Sport _______________________ Explain "Yes" answers below: Yes No 1. Have you ever been hospitalized?........................................................................................... Have you ever had surgery?.................................................................................................... 2. Are you presently taking any medications or pills? .................................................................. 3. Do you have any allergies (medicine, bees or other stinging insects)? ................................... 4. Have you ever passed out during or after exercise? ............................................................... Have you ever been dizzy during or after exercise?................................................................ Have you ever had chest pain during or after exercise?.......................................................... Do you tire more quickly than your friends during exercise? ................................................... Have you ever had high blood pressure? ................................................................................ Have you ever been told that you have a heart murmur?........................................................ Have you ever had racing of your heart or skipped heartbeats? ............................................. Has anyone in your family died of heart problems or a sudden death before age 50?............ 5. Do you have any skin problems (itching, rashes, acne)? ........................................................ 6. Have you ever had a head injury? ........................................................................................... Have you ever been knocked out or unconscious? ................................................................. Have you ever had a seizure? ................................................................................................. Have you ever had a stinger, burner or pinched nerve? .......................................................... 7. Have you ever had heat or muscle cramps? ........................................................................... Have you ever been dizzy or passed out in the heat? ............................................................. 8. Do you have trouble breathing or do you cough during or after activity?................................. 9. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)?. 10. Have you had any problems with your eyes or vision?............................................................ Do you wear glasses or contacts or protective eye wear?....................................................... 11. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)?......... 12. Have you had a medical problem or injury since your last evaluation? .......................... 13. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones or joints. .................................................................................... Head Back Shoulder Forearm Hand Hip Knee Ankle Neck Chest Elbow Wrist Finger Thigh Shin Foot 14. When was your first menstrual period? _________________________________________ When was your last menstrual period?__________________________________________ What was the longest time between your periods last year? _________________________ Explain "Yes" answers: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I hereby state that, to the best of my knowledge, my answers to the above questions are correct. Date _______________________ Signature of athlete ____________________________________________________ Signature of parent/guardian _____________________________________________ Form 5 - Rev. '93 FORM 5 (over) Over for pg 2 of PDF DUPLICATE AS NEEDED LIMITED COMPLETE Cardiovascular Pulses Heart Lungs Skin E.N.T. Abdominal Genitalia (males) Musculoskeletal Neck Shoulder Elbow Wrist Hand Back Knee Ankle Foot Other Normal Abnormal findings Preparticipation Physical Evaluation Physical Examination Height____________ Weight _____________ BP _____ / _____ Pulse ____________ Vision R 20 / ____ L 20 / ____ Corrected: Y N Clearance: A. Cleared B. Cleared after completing evaluation/rehabilitation for: _______________________________________ C. Not cleared for: Collision Contact Noncontact ____ Strenuous ____ Moderately strenuous ____ Nonstrenuous Due to: ___________________________________________________________________________ Recommendation: _______________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Name of physician ______________________________________________________ Date ____________________ Address ______________________________________________________________ Phone___________________ Signature of physician ___________________________________________________, M.D. or D.O. Rule 1, Sec. 13 - No student shall be eligible to represent his/her school in interscholastic athletics unless there is on file in the Superintendent's or Principal's office a physician's statement for the current year certifying that the student has passed an adequate physical examination, and that in the opinion of the examining physician he/she is fully able to participate in high school athletics. Back Form 5
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