The Illinois Pre Participation Physical Form is an essential document required for student athletes before they partake in any sports activities. It includes a comprehensive health history and a physical examination to ensure the athlete is in good health and capable of participating safely in sports. Completing this form accurately is crucial for the safety and wellbeing of the student athletes. If you're preparing for the upcoming sports season, make sure to fill out the form by clicking the button below.
The Illinois Pre Participation Physical form serves a critical role in ensuring the safety and readiness of students before they engage in school athletic activities. This comprehensive document requires detailed input from both the student (or their parent) and medical professionals, covering a wide spectrum of the student's health history and current medical condition. Starting with personal and contact information, the form delves into the student’s medical history, including medication, allergies, and any past medical events or conditions that could influence their participation in sports. Specific sections target heart health, both personal and familial, bone and joint health, general medical questions, and even eye and vision health, illustrating the thoroughness with which the form seeks to uncover any potential risks. Furthermore, the physical examination segment scrutinizes various physical attributes and functions, from the musculoskeletal assessment to cardiovascular health, ensuring the student is fit for athletic endeavors. Notably, the form also touches on sensitive issues like nutrition, weight concerns, and mental health, reflecting a holistic approach to the student's wellbeing. The inclusion of a section for female athletes regarding menstrual health underscores the tailored approach to gender-specific health concerns. Finally, it links to broader public health policies by incorporating consent for random steroid testing, aligning individual health assessments with efforts to maintain fairness and integrity in high school sports. This document thus stands as a pivotal tool in safeguarding student athletes, ensuring they are physically and mentally prepared for the challenges of sports participation.
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
The Illinois Pre Participation Physical form is an essential document for students preparing to engage in athletic activities, ensuring their readiness and ability to safely participate in sports. This detailed form must be filled out accurately, highlighting the student's medical history, allergies, medications, and overall health. It also includes a section for physical examination findings to be completed by a healthcare professional. Completing this form requires attention to detail and honest responses to all questions regarding the student's health status to guarantee their safety during athletic participation.
After submitting the form, the information will be reviewed to ensure the student's eligibility for athletic participation. It is crucial for the safety of the student that all information provided is accurate and truthful. If there are any changes to the student's medical condition after the form has been submitted, it is the responsibility of the student or parent to inform the school immediately.
What is the Illinois Pre Participation Physical form?
The Illinois Pre Participation Physical form is a comprehensive document designed to ensure the safety of students participating in athletic activities. It requires the disclosure of the student's medical history, current medications and allergies, and undergoes a thorough physical examination. This form helps to identify any potential health issues that might affect the student's ability to safely engage in sports.
Who needs to complete the Illinois Pre Participation Physical form?
Any student intending to participate in interscholastic sports within Illinois schools must complete this form. It is a prerequisite for involvement in athletic activities, ensuring the student meets health standards for safe participation.
What information must be provided in the history section of the form?
In the history section, students or their parents must list all prescription and over-the-counter medicines, supplements, and any allergies. It further dives into specific health-related questions covering general health, heart health, bone and joint issues, medical questions involving conditions like asthma, diabetes, and more, as well as questions tailored for female students regarding menstrual history. This section aims to capture a comprehensive health profile of the student.
Can a Physical Assistant or Advanced Nurse Practitioner sign the physical examination form?
Yes, effective January 2003, the Illinois High School Association (IHSA) Board of Directors approved a recommendation consistent with the Illinois School Code that allows Physician's Assistants or Advanced Nurse Practitioners to sign off on physicals.
What does the physical examination entail?
The physical examination covers various assessments including height, weight, blood pressure, pulse, vision, and evaluations of the appearance, eyes/ears/nose/throat, the heart, lungs, abdomen, genitourinary (for males only), skin, neurological function, and the musculoskeletal system. It aims to ensure the student is physically capable of participating in sports without undue risk.
Are students tested for steroid use?
As part of the Illinois High School Association’s commitment to fair play, students may be subject to random testing for performance-enhancing substances during state series events or the school day. The testing protocol is designed to deter the use of banned substances, and the results are kept confidential to the extent required by law.
What happens if the student fails to provide truthful information on the form?
Providing inaccurate or dishonest information on the Illinois Pre Participation Physical form can lead to penalties as determined by the IHSA. It is crucial that students and parents provide complete and accurate health information to ensure the safety of student-athletes.
How often must the Illinois Pre Participation Physical form be completed?
The Illinois Pre Participation Physical form must be completed annually. This ensures that the student’s health information is up-to-date and provides an ongoing assessment of their ability to participate in sports activities safely.
Filling out the Illinois Pre Participation Physical form is a crucial step for student-athletes aiming to participate in sports. However, errors in completing this form can lead to unnecessary delays or even disqualification. Let's explore eight common mistakes to avoid:
Not providing complete and accurate personal information, such as failing to mention the middle name or incorrectly typing the phone number, can lead to confusion and delays in processing the form.
Omitting details about prescription and over-the-counter medications, as well as supplements, can be risky since some substances may influence the athlete's ability to safely participate in sports.
Overlooking to specify allergies, particularly to medicines, pollens, foods, or stinging insects, poses a health risk that coaches and health professionals need to be aware of.
Skipping questions related to past medical history, such as previous denials of sports participation by a doctor or any underlying medical conditions, can hide potential risks.
Forgetting to mention any heart-related symptoms experienced during or after exercise can overlook the potential for serious heart conditions that could be exacerbated by physical exertion.
Neglecting to detail any previous injuries, especially those that led to hospital stays, surgery, or required the use of medical devices like braces or casts, can lead to re-injury.
Failing to discuss family medical history related to heart health or bone and joint issues, which can be crucial for identifying inherited risks.
Inaccurately reporting the female athlete's menstrual history or not disclosing concerns related to weight and diet can overlook significant health issues relevant to physical activity.
By avoiding these eight common mistakes, athletes and their guardians can ensure a smoother approval process, facilitating a safer sports participation environment. This diligence helps in safeguarding the health and well-being of student-athletes, enabling them to compete to the best of their abilities.
Completing the Illinois Pre-Participation Physical form is an essential step for student-athletes in ensuring they are healthy and ready to participate in sports. However, it is not the only document that may be needed to ensure a comprehensive assessment of an athlete's readiness and to comply with all regulations. There are several other forms and documents that are often used alongside the Pre-Participation Physical form.
These documents serve multiple critical functions: they provide a safety net around the health and welfare of the student-athlete, ensure compliance with school and athletic policies, and promote a positive, healthy, and respectful sporting environment. Together with the Pre-Participation Physical form, they form a comprehensive toolkit ensuring that student-athletes are prepared physically, mentally, and administratively for the challenges of school sports.
Similar to the Illinois Pre Participation Physical form, Annual Physical Examination forms are used to document an individual's general health status before participating in activities, employment, or certain educational programs. Just like the Pre Participation form, they cover various health aspects including medical history, immunizations, and a physical examination focusing on vital signs, vision, hearing, and overall physical health. These forms ensure that individuals are in good health and capable of safely engaging in the activities they intend to pursue.
Although primarily focused on the documentation of vaccines received, Vaccination and Immunization Records share a common goal with the Illinois Pre Participation Physical form: ensuring the safety and wellbeing of participants. These records, much like the history section of the physical form, give a snapshot of the individual’s health status, specifically regarding their immunity to contagious diseases, which is crucial for participation in group settings like schools or sports teams.
Sports Clearance Forms are closely aligned with the Illinois Pre Participation Physical form, designed specifically to assess an athlete's fitness level and ensure their readiness for sports participation. They include detailed inquiries about an athlete’s medical history, recent illnesses, injuries, and hospitalizations, in addition to a comprehensive physical examination. The primary objective is to identify any health concerns that could be exacerbated by intense physical activity, mirroring the purpose and structure of the Pre Participation Physical form.
Health Screening Questionnaires serve a similar preventative health measure as the Illinois Pre Participation Physical form, focusing on identifying risk factors and existing health conditions that may affect an individual’s capacity to participate in specific events or programs. These questionnaires often feature detailed health histories, including questions about chronic diseases, allergies, and medication use, akin to the Pre Participation form's sections on medical history and medications. The key aim is to ensure that individuals can safely engage in activities without putting their health at risk.
When completing the Illinois Pre-Participation Physical form, it's important to ensure that all information provided is accurate and reflective of the student athlete's current health status. The following guidelines highlight key dos and don'ts to consider during the process:
Adhering to these guidelines can support a smoother and more effective physical examination process, helping to ensure the safety and well-being of student athletes. It's also a good practice to review the form with a healthcare provider, ensuring all medical information is up-to-date and accurately reflected.
When it comes to the Illinois Pre-Participation Physical Form, a critical document intended to gauge a student's readiness for athletic activities, there exists a handful of misconceptions that can muddy its purpose and process. Understanding these common misinterpretations can help parents, students, and school officials navigate this requirement more effectively.
Misconception 1: It's Just a Formality Many believe the form is merely bureaucratic hoop-jumping. However, it's a crucial screening tool designed to identify health conditions that could make sports participation unsafe.
Misconception 2: Any Doctor Can Sign Off While it might seem that any healthcare professional can sign the form, regulations specify that only a licensed physician, a physician’s assistant under a physician's supervision, or an advanced practice nurse can conduct the examination and approve participation.
Misconception 3: Once Approved, Permanently Approved Approval for participation is not indefinite. The form is valid for just one year, requiring annual re-evaluation to account for any changes in a student’s health status.
Misconception 4: The Physical Exam Is Comprehensive Though thorough, the exam focuses on specific health aspects critical to athletic participation. It is not a substitute for a comprehensive health examination.
Misconception 5: A “No” Answer Means No Participation A "no" to certain questions does not automatically disqualify a student. It signals the need for further evaluation, possibly leading to clearance with specific precautions or modifications.
Misconception 6: The Form Only Covers Physical Health Besides physical health, the form screens for neurological health, mental health, and even familial health history, emphasizing a holistic approach to student-athlete safety.
Misconception 7: Privacy Concerns Are Overlooked Confidentiality is paramount. The information provided is protected, used solely for evaluating eligibility and not disclosed unlawfully.
Misconception 8: It Replaces the Need for Additional Health Screenings While comprehensive, this evaluation does not replace the need for regular health check-ups and specialized assessments for conditions like asthma or heart issues.
Misconception 9: Parental Signatures Are Optional The form requires signatures from both the student and a parent or guardian. This ensures mutual awareness and consent regarding the student’s health and participation readiness.
Dispelling these misconceptions ensures a smoother process for all involved, highlighting the form's role in safeguarding student-athletes’ health and well-being.
Filling out the Illinois Pre Participation Physical form is an essential step for student-athletes planning to participate in sports. This form not only ensures athletes are physically able to compete but also helps to identify any underlying health issues that could impact their performance or well-being. Here are seven key takeaways to consider when completing and using this form:
Properly filling out the Illinois Pre Participation Physical form is a crucial step in ensuring student-athletes are safe and healthy as they engage in sports activities. It provides a comprehensive overview of the athlete's medical history, current health status, and readiness to participate, helping to protect the health and safety of young athletes across Illinois.
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