THE SOUTH CAROLINA INDEPENDENT SCHOOL ASSOCIATION

Pre-Participation History & Health Assessment

Name __________________________________ Date of Birth: _____________________ Grade: _________
School: _________________________________ Sex: F ____ M ____ Sports: _________________________
Address: _____________________________________________________ Phone: ______________________
Personal Physician: ___________________________________________ Phone: ________________________
In Case of an Emergency Contact: __________________________________ Relationship: ________________
Home Phone #: _______________________ Cell #: _______________________ Other: ________________
Attention parent or guardian and athlete: answers to the following questions are very important! Please take the time to answer each
question to the best of your knowledge.

General Medical History: General Medical History:

Yes No Yes No
1. Do you have asthma? ………….…………...…. ___ ___ 23. Do you want to weigh more/less than you do now? ___ ___
2. Do you have diabetes? ……………………….... ___ ___ 24. Do you lose weight regularly to meet weight
3. Do you have high blood pressure? ………….…. ___ ___ requirements for your sport or other reasons? ……. ___ ___
4. Do you have seizures? …………………….…… ___ ___ 25. Do you feel stressed out, tired or depressed? …….. ___ ___
5. Do you have sickle cell trait? ……………….… ___ ___ 26. Are there any issues that you would like to discuss
6. Do you have any other major medical problems? ___ ___ with the doctor? …………………………………... ___ ___
7. Have you ever been hospitalized or had surgery? ___ ___ 27. Are your immunizations up to date? ……………... ___ ___
8. Do you cough, wheeze or have trouble breathing Females Only
with exercise? …………………...…………..… ___ ___ 28. Are your periods regular (every month)? ………... ___ ___
9. Do you use an inhaler? ……………………….... ___ ___ 29. Are your periods heavy? …………………….….... ___ ___
10. Do you have a single organ, testicle or kidney? ___ ___ Cardiac History
11. Are you currently taking any medicines on 1. Have you ever passed out during or after exercise? ___ ___
a regular basis (prescription or over-the-counter)? ___ ___ 2. Have you ever been dizzy during or after exercise? ___ ___
12. Have you ever taken supplements or vitamins 3. Have you ever had chest pains or chest pressure
to help with weight loss, weight gain or improve during or after exercise? …………………………. ___ ___
performance? ………………………………….. ___ ___ 4. Do you tire easily or more quickly than your
13. Do you have any allergies (seasonal, insects, friends during exercise? ………………………….. ___ ___
Food, latex or medicines)? ………………..…… ___ ___ 5. Have you ever had racing of your heart or skipped
14. Have you ever had a rash or hives develop heartbeats? ………………………………………. ___ ___
during or after exercise? …………….…………. ___ ___ 6. Have you been told you had a heart murmur? ___ ___
15. Do you have a skin problem other than acne?…. ___ ___ 7. Have you ever been told that you had an enlarged
16. Have you ever had a head injury, been knocked or weak heart? ……………………………………. ___ ___
out, lost your memory, had your “bell rung” or 8. Has any member of your family:
a concussion? …………………………………. ___ ___ Died of heart problems or sudden death before age 50? ... ___ ___
17. Have you ever had numbness or tingling in your Been told they had a serious heart problem before age 50? ___ ___
arms, hands, legs, or feet? …………………….. ___ ___ Been told they had Marfan Syndrome?............................ ___ ___
18. Have you had a stinger, burner or pinched nerve? ___ ___ 9. Has a physician ever restricted your participation in
19. Have you ever become ill from exercising in sports? …………………………………………… ___ ___
the heat? ………………………………………… ___ ___
20. Have you had mononucleosis or any significant Orthopedic History
illness in the last 60 days? ……………………… ___ ___ 1. Have you ever broken or fractured any bones? ….. ___ ___
21. Do you have trouble with your eyes/wear glasses?___ ___ 2. Have you ever dislocated any joint? …………….. ___ ___
22. Do you have trouble with your hearing/wear 3. List any other problems with neck, spine, back, shoulders, elbows,
wrists, hands, fingers, hips, knees, ankles, feet or toes
hearing aids? …………………………………. ___ ___

Explain “Yes” Answers on another page (put date of injury if known)

Parent’s Permission & Acknowledgement of Risk for Son or Daughter to Participate in Athletics
As the parent or legal guardian of the above named student athlete, I give my permission for his/her participation in athletic events and the
physical evaluation for that participation. I understand that this is simply a screening evaluation and not a substitute for regular health care.
I also grant permission for treatment deemed necessary for a condition arising during participation in these events, including medical or
surgical treatment that is recommended by a medical doctor. I grant permission to nurses, trainers, coaches, doctors or those under their
direction who are part of the athletic injury prevention or treatment, to have access to necessary medical information. I know that the risk
of injury to my child/ward comes with participation in sports and during travel to and from play and practice. My signature indicates that to
the best of my knowledge, my answers to the above questions are complete and correct.
Signature of athlete ________________________________________________________ Date ________________________
Signature of parent/guardian _________________________________________________ Date ________________________
 SOUTH CAROLINA INDEPENDENT SCHOOL ASSOCIATION
Please Print Medical Examination Form
_____________________________________________________ __________________________
Last Name First Name Middle Initial Date of Birth

Gender: M F SS# ________________________________ Age: _______ Grade: ________

PHYSICAL EXAM - To Be Completed By Physician
Height ___________ Weight ___________ Pulse ___________ Blood Pressure ___________
Normal Abnormal Findings Initials
1. Eyes (vision)
2. Ears, Nose, Throat
3. Mouth & Teeth
4. Neck
5. Cardiovascular
6. Abdomen
7. Chest & Lungs
8. Skin
9. Genitalia-Hernia (male)
10. Musculoskeletal:
ROM, strength, etc.
 Neck
 Spine
 Shoulders
 Arms/hands
 Hips
 Thighs
 Knees
 Ankles
11. Neuromuscular

____ Cleared without restriction

____ Cleared, with recommendations for further evaluation or treatment for: __________________
_____________________________________________________________________________________

____ Not Cleared: ___ All Sports ____ Certain Sports: _________________________________

I certify that I have examined this athlete on this date and found him/her medically qualified to participate
in sports. I also certify that I am a licensed physician.

Physician’s Signature: _______________________________________ Date: ____________________

Physician’s Address: ___________________________________________________________________