This form should be maintained by the healthcare provider completing the physical exam (medical home).
It should not be shared with
schools. The medical eligibility form is the only form that should be submitted to a school. The physical exam must be completed by a
healthcare provider who is a licensed physician, advanced practice nurse or physician assistant who has completed the Student -Athlete
Cardiac Assessment Professional Development module hosted by the New Jersey Department of Education.
■ PREPARTICIPATION PHYSICAL EVALUATION (Interim Guidance)
HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Date of examination: _______________________________ Sport(s): _____________________________________________________
Sex assigned at birth (F, M, or intersex): __________ How do you identify your gender? (F, M, non-binary, or another gender): __________
Have you had COVID-19? (check one): Y N
Have you been immunized for COVID-19? (check one): Y N If yes, have you had: One shot Two shots
Three shots Booster date(s) ______________________
List past and current medical conditions. _____________________________________________________________________________
_______________________________________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
_______________________________________________________________________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Patient Health Questionnaire Version 4 (PHQ-4)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
GENERAL QUESTIONS HEART HEALTH QUESTIONS ABOUT YOU
(Explain “Yes” answers at the end of this form. Circle (CONTINUED ) Yes No
questions if you don’t know the answer.) Yes No 9. Do you get light-headed or feel shorter of breath
1. Do you have any concerns that you would like to than your friends during exercise?
discuss with your provider?
10. Have you ever had a seizure?
2. Has a provider ever denied or restricted your
participation in sports for any reason? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Unsure Yes No
3. Do you have any ongoing medical issues or recent 11. Has any family member or relative died of
illness? heart problems or had an unexpected or
unexplained sudden death before age 35
HEART HEALTH QUESTIONS ABOUT YOU Yes No
years (including drowning or unexplained car
4. Have you ever passed out or nearly passed out crash)?
during or after exercise?
12. Does anyone in your family have a genetic
5. Have you ever had discomfort, pain, tightness,
heart problem such as hypertrophic cardio-
or pressure in your chest during exercise?
myopathy (HCM), Marfan syndrome, arrhyth-
6. Does your heart ever race, flutter in your chest, mogenic right ventricular cardiomyopathy
or skip beats (irregular beats) during exercise? (ARVC), long QT syndrome (LQTS), short QT
syndrome (SQTS), Brugada syndrome, or
7. Has a doctor ever told you that you have any
catecholaminergic polymorphic ventricular
heart problems?
tachycardia (CPVT)?
8. Has a doctor ever requested a test for your
heart? For example, electrocardiography (ECG) 13. Has anyone in your family had a pacemaker
or echocardiography. or an implanted defibrillator before age 35?
BONE AND JOINT QUESTIONS Yes No MEDICAL QUESTIONS (CONTINUED ) Yes No
14. Have you ever had a stress fracture or an injury to a 25. Do you worry about your weight?
bone, muscle, ligament, joint, or tendon that caused 26. Are you trying to or has anyone recommended that
you to miss a practice or game? you gain or lose weight?
15. Do you have a bone, muscle, ligament, or joint 27. Are you on a special diet or do you avoid certain
injury that bothers you? types of foods or food groups?
MEDICAL QUESTIONS Yes No 28. Have you ever had an eating disorder?
16. Do you cough, wheeze, or have difficulty breathing MENSTRUAL QUESTIONS N/A Yes No
during or after exercise? 29. Have you ever had a menstrual period?
17. Are you missing a kidney, an eye, a testicle, your 30. How old were you when you had your first menstrual
spleen, or any other organ? period?
18. Do you have groin or testicle pain or a painful bulge 31. When was your most recent menstrual period?
or hernia in the groin area? 32. How many periods have you had in the past 12
19. Do you have any recurring skin rashes or months?
rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus (MRSA)? Explain “Yes” answers here.
______________________________________________________
20. Have you had a concussion or head injury that
______________________________________________________
caused confusion, a prolonged headache, or
memory problems? ______________________________________________________
______________________________________________________
21. Have you ever had numbness, had tingling, had
weakness in your arms or legs, or been unable to ______________________________________________________
move your arms or legs after being hit or falling? ______________________________________________________
22. Have you ever become ill while exercising in the
______________________________________________________
heat? ______________________________________________________
______________________________________________________
23. Do you or does someone in your family Unsure
have sickle cell trait or disease? ______________________________________________________
______________________________________________________
24. Have you ever had or do you have any problems ______________________________________________________
with your eyes or vision?
______________________________________________________
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete
and correct.
Signature of athlete: ______________________________________________________________________________________________________
Signature of parent or guardian: __________________________________________________________________________________________
Date: ________________________________________________________
© 2023 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, educa-
tional purposes with acknowledgment.
