TO: School Administrators

FROM: AAA Office

RE: Physical Exam Forms

The Executive Committee of the Arkansas Activities Association is

recommending the use of the enclosed physical exam forms.

Form A and Form B are recommended to be used for students the first time
they participate in Junior High and again the first time they participate in
Senior High.

Form C may be used in intervening years. These physical exams will be in

effect for one calendar year except for those students experiencing physical
problems during that year and may need to be re-evaluated.

Form A is a medical history form and requires parental involvement and a

parent’s signature. Forms B and C shall be signed by the person
administering the physical and a parent if applicable.

We hope that these forms will help alleviate concerns expressed by schools
and physicians related to the physical health of athletes and spirit group
participants.
FORM A
Preparticipation Physical Evaluation
HISTORY Date

Name Sex Age Date of birth

Grade Sport

Personal physician
Physician's Address Physician's Phone

Explain "Yes" answers below:

1. Have you ever been hospitalized? .................................................. Yes No

2. Are you presently taking any medications or pills? ................................ Yes No
3. Do you have any allergies (medicine, bees or other stinging insects)? ............. Yes No
4. Have you ever passed out during or after exercise? ................................ Yes No
5. Have you ever been dizzy during or after exercise? ............................. Yes No
6. Have you ever had chest pain during or after exercise? ............................ Yes No
7. Do you tire more quickly than your friends during exercise? ....................... Yes No
8. Have you ever had high blood pressure? ............................................ Yes No
9. Have you ever been told that you have a heart murmur? ............................. Yes No
10. Have you ever had racing of your heart of skipped heartbeats? ..................... Yes No
11. Has anyone in your family died of heart problems or a sudden death before age 50? . Yes No
12. Do you have any skin problems (itching, rashes, acne)? ............................ Yes No
13. Have you ever had a head injury? .................................................. Yes No
14. Have you ever been knocked out or unconscious? .................................... Yes No
15. Have you ever had a seizure? ...................................................... Yes No
16. Have you ever had a stinger, burner or pinched nerve? ............................. Yes No
17. Have you ever had heat or muscle cramps? .......................................... Yes No
18. Have you ever been dizzy or passed out in the heat? ............................... Yes No
19. Do you have trouble breathing or do you cough during or after activity? ........... Yes No
20. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc)? .................. Yes No
21. Have you had any problems with your eyes or vision? ............................... Yes No
22. Do you wear glasses or contacts or protective eye wear? ........................... Yes No
23. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or
other injuries of any bones or joints? ............................................ Yes No
Head Shoulder Thigh Neck Elbow Knee Chest Forearm
Shin/Calf Back Wrist Ankle Hip Hand Foot
24. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)? Yes No
25. Have you had a medical problem or injury since your last evaluation? .............. Yes No
26. When was your last tetanus shot? .........................................................
27. When was your last measles immunization? .................................................
28. When was your first menstrual period? ....................................................
29. When was your last menstrual period? .....................................................
30. When 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

SUBS\SCHOOLS\MAY\MEDFORM
FORM B
Preparticipation Physical Evaluation (continued)
Physical Examination Date

Name Age Date of birth

Height Weight BP / Pulse

Vision (R) 20/ (L) 20/ Corrected Y N Pupils

Normal Abnormal Findings Initial

LIMITED

Cardiopulmonary

Pulses

Heart

Lungs

Tanner Stage 1 2 3 4 5
COMPLETE

Skin

Abdominal

Genitalia

Musculoskeletal

Neck

Shoulder

Elbow

Wrist

Hand

Back

Knee

Ankle

Foot

Other

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/Medical Personnel Date

Address Phone

Signature of Physician/Medical Personnel

SUBS\SCHOOLS\MAY\MEDFORM
FORM C
Arkansas Activities Association Physical Exam Form

Master Problem List Date Identified Date Resolved

1.

2.

3.

4.

Date Entrance Physical Examination

PAST MEDICAL HISTORY: Since your initial preparticipation physical examination have you had any
of the following? (If yes, please explain what, where and when)

Yes No Explanation

1. Presently taking medication (including birth control pills)?

2. Allergic to medicine, food, bee-sting?

3. Wearing any new appliances - glasses, contact lenses,

dentures or hearing aids?

4. History of braces, chipped teeth, bridges?

5. New medical problem requiring treatment or medication?

6. Surgical operations or accidents requiring medical help?

7. Injuries directly related to sports participation? (If so,

explain nature of injury)

8. Recent fainting or dizziness while exercising?

9. Recent head injury of loss of consciousness?

10.(For women) Date of last menstrual period?

REVIEW OF SYSTEMS: Please check if you have developed any new problem to the following areas of your body
since your last physical exam.

Skin Neck Head Lungs Knees Eyes Heart

Mouth/Throat Abdomen Hips, Legs, Feet Blood Urination, bowel

Shoulders, arms, hands Genital (including menstrual for females)

Nutrition, weight control Muscle strength, feeling Mental, emotional

I would like to meet with the team physician Yes No

I certify that the above information is correct to the best of my knowledge.

Student/Parent Signature

VITAL SIGNS:

Height Weight

Vision Screening (optional) (R) 20/ (L) 20/ w/o Glasses

(R) 20/ (L) 20/ with Glasses

Blood Pressure Pulse

Other Testing:

REVIEW BY MEDICAL STAFF:

Approved for participation Other disposition

Must see physician

Medical Personnel Signature Date