2021 PSAL Pre-Participation Physical Exam PDF

PSAL Pre-Participation Physical Exam Please Note: An additional page has been added to the form entitled “PSAL Health History COVID Addendum.” Please take all four pages of the form to your medical provider. The only page that gets returned to the Athletic Director is titled “R...

PSAL Pre-Participation Physical Exam Please Note: An additional page has been added to the form entitled “PSAL Health History COVID Addendum.” Please take all four pages of the form to your medical provider. The only page that gets returned to the Athletic Director is titled “Recommendations for Participation in Physical Education and Sport.”  HISTORY FORM | Preparticipation Physical Evaluation (Note: This form is to be filled out by the patient and parent prior to seeing the medical provider. The medical provider should keep this form in the student’s medical file. This form does not get returned to the athletic department.) Date of Exam Date of Birth OSIS# Last Name First Name Sport(s) Sex Age Grade School School Campus 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 carry an inhaler? q Yes  q No Do you have any allergies?  q Yes  q No If yes, please identify specific allergy below: Do you carry an Epi Pen?   q Medicines q Pollens    q Food    q Stinging Insects    q Latex   q Yes  q No Explain “Yes” answers below. Circle questions you don’t know the answers to GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No 1. Has a doctor ever denied or restricted your participation in sports for 25. Do you have any history of juvenile arthritis or connective tissue disease? any reason? 26. Do any of your joints become painful, swollen, warm, or look red? 2. Do you have any ongoing medical conditions? If so, please identify below: 27. Do you cough, wheeze, or have difficulty breathing during or after exercise? q Asthma q Anemia q Diabetes q Infections q sickle cell disease or trait 28. Have you ever used an inhaler or taken asthma medicine? Other: 29. Is there anyone in your family who has asthma? 3. Have you ever been admitted to the hospital? 30. Were you born without or are you missing a kidney, an eye, a testicle (males), 4. Have you ever had surgery? your spleen, or any other organ? HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Do you have groin pain or a painful bulge or hernia in the groin area? 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 32. Have you had infectious mononucleosis (mono) within the last month? 6. Have you ever had discomfort, pain, tightness, or pressure in your 33. Do you have any rashes, pressure sores, or other skin problems? chest during exercise? 34. Have you had a herpes or MRSA skin infection? 7. Does your heart ever race or skip beats while resting or during exercise? 35. Have you ever had a head injury or concussion? 8. Has a doctor ever told you that you have any heart problems? If so, 36. Have you ever had an unexplained seizure? check all that apply: q High blood pressure q A heart murmur 37. Have you ever had a hit or blow to the head that caused confusion, q High cholesterol q A heart infection q Kawasaki disease long-lasting headache, or memory problems? Other: 38. Do you have a history of seizure disorder? 9. Has a doctor ever ordered a test for your heart? 39. Do you have headaches with exercise? (For example, ECG/EKG, echocardiogram) 40. Have you ever had numbness, tingling, or weakness in your arms or 10. Do you get lightheaded or feel more short of breath than expected legs after being hit or falling? during exercise? 41. Have you ever been unable to move your arms or legs after being hit or falling? 11. Do you get more tired or short of breath more quickly than your friends 42. Have you ever become ill while exercising in the heat? during exercise? 43. Do you get frequent muscle cramps when exercising? 12. Have you ever had any heart surgery? 44. Have you had any problems with your eyes or vision? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 45. Have you had any eye injuries? 13. Does anyone in your family have an irregular heartbeat? 46. Do you wear glasses or contact lenses? 14. Has any family member of relative died of heart problems or had an 47. Do you wear protective eyewear, such as goggles or a face shield? unexpected or unexplained sudden death before age 50 (including drowning, 48. Have you ever had hearing loss or problems with your hearing? unexplained car accident, or sudden infant death syndrome)? 49. Do you worry about your weight? 15. Does anyone in your family have a heart problem, pacemaker, or defibrillator? 50. Are you trying to or has anyone recommended that you gain or lose weight? 16. Has anyone in your family had unexplained fainting, unexplained seizures, 51. Are you on a special diet or do you avoid certain types of foods? or near drowning? 52. Have you ever had an eating disorder? 17. Do you or someone in your family have sickle cell trait or disease? 53. Do you have any concerns that you would like to discuss with a doctor? BONE AND JOINT QUESTIONS Yes No 54. Do you have any other medical problems? 18. Have you ever had an injury to a bone, muscle, ligament, or tendon FEMALES ONLY Yes No that caused you to miss a practice or a game? 55. Have you ever had a menstrual period? 19. Have you ever had any broken or fractured bones or dislocated joints? 56. Have you had any problems with your periods (severe cramps, heavy bleeding? 20. Have you ever had an injury that required x-rays, MRI, CT scan, injections, 57. When was your last period? ______________________________________________ therapy, a brace, a cast, or crutches? 58. What is the frequency of your periods? ______________________________________ 21. Have you ever had a stress fracture? Explain “yes” answers here 22. Have you ever been told that you have or have you had an x-ray for neck instability? (Down syndrome or dwarfism) 23. Do you regularly use a brace, orthotics, or other device? 24. Do you have a bone, muscle, or joint injury that bothers you? I have reviewed the History Form and I hereby state that, to the best of my knowledge, the answers to the above Parent/Guardian Name questions are complete and correct. I give permission for ______________ (Child’s Name) to have a physical Parent/Guardian Signature Date examination, which will include an inguinal and testicular examination for boys and an inguinal examination for girls. If this exam is performed in the school setting, I understand that if either I or my child refuses to have these Phone # areas examined, the OSH Medical provider will not be able to complete this form and clear my child for participation. NYC_ED_AAP_PPE_HISTORY_FORM_09162019 PAGE 1  PSAL Health History COVID Addendum (to be completed and signed by parent/guardian within 30 days before sports participation) COVID-19 Information (Check Yes or No for each question) YES NO 1. Has your child ever tested positive for COVID-19? 2. Did your child ever have symptoms of COVID-19 infection? (Symptoms could include fever, chills, fatigue, body aches, new loss of smell or taste, unexplained cough, shortness of breath or trouble breathing) 3. Did your child ever see a healthcare provider (HCP) for COVID-19 symptoms? 4. Did your child have any of the symptoms below? (If yes, please add more information.) -New fast or slow heart rate -Chest pain or tightness -New or unexplained fainting or fatigue -A new heart condition or blood pressure changes diagnosed by a health care provider If yes, is your child under a health care provider’s care for this? 5 Was your child hospitalized? If yes, provide date(s):. If yes, was your child diagnosed with Multisystem Inflammatory syndrome (MISC)? If yes, is your child under a health care provider’s care for this? Please explain fully any question you answered yes to in the space below, include dates if known. Use additional pages if necessary. Parent/Guardian Signature: ______________________________________ Date: ____________ Adapted from the NYS Center for School Health located at www.schoolhealthny.com – 12/2020 REV. 3/21  PHYSICAL EXAMINATION FORM | Preparticipation Physical Evaluation NOTE: The medical provider should keep this form in the student’s medical file. This form does not get returned to the athletic department. Last Name First Name Date of Birth School/Campus/ATSDBN Grade OSIS# STUDENT’S HISTORY FORM REVIEWED BY MEDICAL PROVIDER YES NO PHYSICIAN REMINDER - Consider the questions below COMMENTS Do you feel safe at your home or residence? Do you feel safe at school? Do you ever feel stressed out or under a lot of pressure? Do you ever feel sad, hopeless, depressed, or anxious? Have there been any changes in your weight? Have you ever taken any supplements to help you gain or lose weight or improve your performance? Have you ever taken anabolic steroids or used any other performance supplement? Have you ever tried cigarettes, alcohol, or other drugs? During the past 30 days, did you use cigarettes, alcohol or other drugs? Are you sexually active? Are you using contraceptives? Do you wear a seat belt? EXAMINATION Height Weight q Male q Female BP Pulse Vision R20/ Corrected / L20/ q Yes q No MEDICAL NORMAL ABNORMAL FINDINGS Appearance Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP) Eyes/ears/nose/throat Pupils equal Hearing Lymph nodes Hearta 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 Neurologicc MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS Neck Back (including scoliosis screening) Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional Duck-walk, single leg hop Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.b GU exam must be done in a private setting; the presence of a third party/chaperone is needed. It should not be a performed in mass participation settings. Cconsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion. I have examined the above named student and completed the pre-participation physical examination. The athlete may/may not participate in the sport(s) outlined on the Recommendations for Participation in Physical Education and Sports form. This form may be rescinded until the potential consequences of the health issue are explained to both the student and his/her parents, and the health issue has been resolved. All information and recommendations contained herein are valid through the last day of the month for 12 months from the date below. Name of medical provider (print/type) Date License/NPI Number Address Phone Signature of Medical Provider , MD/DO/NP/PA STAMP HERE NYC_ED_AAP_PPE_HISTORY_FORM_09162019 PAGE 2  RECOMMENDATIONS FOR PARTICIPATION IN PHYSICAL EDUCATION & SPORTS To be completed by student’s health care provider or school medical provider This page must be submitted to coach or athletic director before PSAL participation. Last Name First Name OSIS# Grade School/Campus/ATSDBN q CLEARED FOR ALL SPORTS WITHOUT RESTRICTION q NOT CLEARED Duration: q NOT CLEARED PENDING FURTHER EVALUATION q C  LEARED FOR ALL SPORTS WITHOUT RESTRICTION WITH RECOMMENDATIONS FOR FURTHER EVALUATION OR TREATMENT FOR: q CLEARED WITH RESTRICTIONS/ADAPTATIONS/ACCOMMODATIONS Duration: q NO CONTACT SPORTS: q NO LIMITED CONTACT SPORTS: q NO NON-CONTACT SPORTS: includes includes basketball, competitive includes baseball, cross-country skiing, archery, badminton, bowling, cricket, cheerleading, diving, field hockey, fencing, flag football, handball, high jump, discus, double dutch, golf, javelin, race football (tackle), gymnastics, ice hockey, ice skating, pole vault, skiing, softball, walking, rifle, shot-put, swimming, table lacrosse, rugby, soccer, stunt, wrestling volleyball tennis, tennis, track & field q OTHER RESTRICTIONS ACCOMMODATIONS/PROTECTIVE EQUIPMENT q None q Athletic Cup q Sports/Safety Goggles q Medical/Prosthetic Device q Pacemaker q Insulin Pump/Insulin Sensor q Brace/Orthotic q Hearing Aides q Protective Ear Gear q Other _____________________________ q PERTINENT MEDICAL HISTORY q ALLERGIES q None MEDICATIONS q Has prescribed pre-exercise medication q Has prescribed PRN medication qStudent is Self-Carry/Self-Administer, unless in an emergency or student is incapable of self-administration Explanation q OTHER RECOMMENDATIONS I have examined the above named student and completed the pre-participation physical examination, INCLUDING A REVIEW OF ANY I have examined the above named student and completed the pre-participation physical examination. The athlete may/may not MEDICAL HISTORY RELATED TO COVID-19. The athlete may/may not participate in the sport(s) as outlined above. A copy of the participate in the sport(s) as outlined above. A copy of the physical exam will be provided to the school medical room staff and can physical exam will be provided to the school medical room staff and can be made available to the school administration at the request of be made available to the school administration at the request of the parents. This form may be rescinded: by a medical provider the parents. This form may be rescinded: by a medical provider if there are any changes in the student’s health that could affect his/her if there are any changes in the student’s health that could affect his/her safe participation in sports, and/or until the potential safe participation in sports, and/or until the potential consequences of the health issue are explained to both the student and his/her consequences of the health issue are explained to both the student and his/her parents, and the health issue has been resolved. All parents, and the health issue has been resolved. All information and recommendations contained herein are valid through the last day of theinformation and recommendations contained herein are valid through the last day of the month for 12 months from the date below. month for 12 months from the date below. Name of medical provider (print/type) Title License/NPI Address Medical Provider’s Stamp Phone Fax Email Signature of medical provider Date ______________________________________________ NYC_ED_PSAL_Sports_Clearance_Form_09162019 PAGE 3