The Illinois Pre Participation Physical form is a comprehensive document created to assess the medical fitness of students before they participate in athletic activities. This form ensures that athletes, or their parents, provide detailed health information and history, which is crucial for identifying potential risks during sports participation. It is meticulously designed to cover various health aspects, including general questions, heart health, bone and joint issues, medical queries, and a specific section for female athletes. Ensure the safety and readiness of student athletes by completing the Illinois Pre Participation Physical form. Click the button below to get started.
In the realm of youth athletics in Illinois, ensuring the safety and readiness of student-athletes for participation is a paramount concern. The Illinois Pre-Participation Physical form serves as a crucial tool in this process, meticulously designed to assess the medical eligibility of students before they embark on sports activities. This comprehensive document covers a vast array of health aspects, beginning with detailed personal information and extending through an exhaustive list of medical questions aimed at uncovering any potential risks that could impede a student’s ability to safely participate in sports. Areas covered include, but are not limited to, a history of medications and allergies, inquiries into heart health, bone and joint conditions, general medical questions, and specific considerations for both male and female athletes. Additionally, the form probes into family medical history to identify hereditary conditions that might affect the student’s health in the context of physical exertion. Beyond these health questions, the form includes a section for a physical examination to be completed by a qualified healthcare professional, evaluating the student's current health status through various medical checks. Furthermore, it addresses the Illinois High School Association’s (IHSA) policies on steroid testing, emphasizing the importance of fair play and the well-being of student-athletes. With such detailed scrutiny, the Illinois Pre-Participation Physical Form plays an instrumental role in fostering a safe and healthy environment for student-athletes to thrive in their athletic pursuits.
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
Before any athlete can participate in sports, it's vital to have a Pre-Participation Physical Examination form filled out thoroughly. This form ensures the athlete is medically and physically ready to take part in sporting activities. Filling out this form correctly is not just about ticking boxes; it provides important health information that might be crucial in preventing serious complications during physical activities. Here's how you can fill out the Illinois Pre-Participation Physical form step by step.
Ensure all sections of the form are filled out completely. Any incomplete information might delay the athlete's participation in sports activities. Remember, the goal of this form is not just to enable participation but to safeguard the athlete's health during their sporting endeavors.
When gearing up for participation in school sports in Illinois, students and their families often have questions about the Illinois Pre-Participation Physical form. This comprehensive document is essential for ensuring athletes are healthy and ready to engage in sports. Here's a helpful list of frequently asked questions to guide you through the process:
This form is a detailed health assessment meant to evaluate a student's fitness to participate in school sports. It gathers information on the student's medical history, allergies, medications, and includes a physical examination section to be completed by a healthcare provider. The goal is to identify any health issues that might affect the student's ability to safely participate in sports activities.
Any student who wishes to participate in school sports activities in Illinois is required to complete this form. It's an essential step in the pre-participation evaluation process, ensuring that the student athlete is medically cleared for sports activities.
The medical history section asks about prescription and over-the-counter medicines, supplements, allergies, and past medical experiences like hospital stays or surgeries. It also covers questions tailored to assess the risk of heart disease, bone and joint injuries, respiratory conditions, and other medical concerns.
Heart health is crucial for athletes, as intense exercise can stress the heart. Questions related to heart health, both personal and familial, are included to identify conditions like arrhythmias, congenital heart defects, and other issues that may require further evaluation to ensure safe participation in sports.
If you answer "Yes" to any questions, especially those related to significant medical issues or symptoms, you should explain your answer in detail in the space provided. This may prompt your healthcare provider to conduct further assessments or tests to ensure you're safe to participate in sports.
The physical examination can be conducted by a licensed physician, physician's assistant, or advanced nurse practitioner. This ensures that the examination is thorough and meets the required health standards for athletic participation.
The physical examination includes checking the athlete's height, weight, blood pressure, pulse, vision, and overall physical appearance. It assesses cardiovascular health, musculoskeletal condition, neurologic function, and other areas crucial for athletic participation.
Yes, a parent or guardian must sign the form, providing consent for the student's participation in sports and acknowledging the accuracy of the information provided. For high school students, consent is also required for the IHSA's steroid testing policy as part of the agreement to participate in sports.
This form must be completed annually. The physical examination part of the form is typically valid for one year, ensuring that a student's health status is up-to-date and they are cleared each year for sports participation.
The completed form should be submitted to the school's sports department or athletic director before the student begins participating in any sports activities. It's important to keep copies of the form for your records as well.
Remember, the Illinois Pre-Participation Physical form is more than just paperwork; it's a crucial step in ensuring the safety and well-being of student athletes. If you have any questions or concerns about completing the form, don't hesitate to reach out to your healthcare provider or school's athletic department for guidance.
Filling out the Illinois Pre-Participation Physical form is a critical step in ensuring the health and safety of students who participate in sports. However, people often make several mistakes during this process, which can affect the student’s eligibility and well-being. Below are six common mistakes to avoid:
Avoiding these mistakes can help ensure that the physical examination and health history review provide an accurate representation of the student's medical status, leading to safer participation in sports.
When it comes to ensuring a comprehensive evaluation and compliance in the school sports realm within Illinois, the Illinois Pre-Participation Physical Form plays a pivotal role. However, this document doesn't stand alone. Accompanying forms and documents often work in conjunction to paint a full picture of a student athlete's eligibility and health status. Understanding these supplementary documents helps streamline the process for students, parents, and school administrators alike.
Together, these documents reinforce the Illinois Pre-Participation Physical Form, ensuring student athletes are physically and medically prepared for athletic participation. They promote a safe and informed athletic environment, addressing medical history, emergency care, insurance coverage, and the commitment to a drug-free sport. Each plays a key role in safeguarding the well-being of student athletes, thus contributing to a positive and successful sports experience.
The Illinois Pre-Participation Physical form is similar to other documents used in the healthcare and educational sectors to assess an individual's readiness and capability to engage in certain activities, specifically those that may exert physical strain. These other documents often aim to identify potential health risks before participation and include, but are not limited to, medical clearance forms for employment, routine physical examination forms, and sports-related health assessment forms used by other states or organizations.
Medical Clearance Forms for Employment: Similar to the Illinois Pre-Participation Physical form, medical clearance forms for employment assess an individual's health and physical ability to perform job-related duties safely. These forms typically include sections that record vital statistics, medical history, vaccinations, and the results of physical examinations conducted to evaluate the respiratory, cardiovascular, musculoskeletal, and neurological systems among others. Both types of forms seek to ensure that the person is physically capable of handling certain tasks without risking their health or the health of others, although the employment-related forms may place a stronger emphasis on the ability to perform job-specific tasks.
Routine Physical Examination Forms: Routine physical examination forms, used in annual health check-ups, closely resemble the Illinois Pre-Participation Physical form in structure and purpose. They document personal information, medical history, medications, allergies, and the findings from a physical examination. Both forms aim to provide a comprehensive overview of an individual's health status, highlighting any areas of concern that may require further investigation or management. However, the focus of the pre-participation physical is more on determining fitness for sports participation, while the routine physical aims for a general assessment of health.
Sports-Related Health Assessment Forms Used by Other States or Organizations: These forms are directly comparable to the Illinois Pre-Participation Physical form, as they are designed with the same objective: to assess the health and physical readiness of individuals looking to participate in sports or athletic activities. They typically include sections on medical history, family history of diseases, allergies, medications, and a physical examination overview, which may encompass assessments of height, weight, blood pressure, heart rate, and musculoskeletal condition. Although the specific questions and format may vary, the underlying goal is to safeguard the athlete's health and safety by identifying any conditions that could be exacerbated by physical exertion.
When completing the Illinois Pre Participation Physical form, ensuring accuracy and thoroughness is critical for the health and safety of the athlete. Here are some dos and don’ts to consider:
When it comes to sports participation in schools, the Illinois Pre Participation Physical form plays a crucial role in ensuring the health and safety of student-athletes. However, there are several misconceptions surrounding this vital document. Understanding these misconceptions is key to ensuring that students, parents, and guardians navigate the process successfully.
Misconception 1: The physical form is only about assessing a student's current health status.
Misconception 2: Once completed, the form is valid for any sports activity indefinitely.
Misconception 3: All sections of the form must be completed by a physician.
Misconception 4: Signing the IHSA Steroid Testing Policy Consent is optional.
Dispelling these misconceptions about the Illinois Pre Participation Physical form is vital for a smooth and compliant entry into school sports programs. By clarifying these points, students, parents, and educators can work together more effectively to ensure the health and safety of all student-athletes participating in sports.
The Illinois Pre-Participation Physical form is a critical document designed to ensure the safety and well-being of students engaging in athletic activities. This comprehensive evaluation aims to identify any health concerns that could affect a student's ability to participate in sports safely. Here are seven key takeaways about filling out and using this important form:
Completing the Illinois Pre-Participation Physical form is a crucial step in preparing for a safe and healthy athletic season. By accurately reporting health history and undergoing a comprehensive physical examination, students, parents, and schools can work together to ensure a safe, enjoyable sports experience.
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