Pre-Participation Physical Evaluation PPE: Pre-Participation Physical Evaluation Today's Date * ORGANIZATION INFORMATION Organization Name * Organization Email * ATHLETE INFORMATION Name Name First First Last Last Date of Birth * Sport * Choose Sport...BaseballBasketballBowlingCross-CountryField HockeyFencingFootballGolfHockeyLacrosseRugbyRowingSoccerSoftballSwimmingTennisTrack & FieldVolleyball Biological Sex * Male Female Intersex HEALTH HISTORY List past and current medical conditions. * Have you ever had surgery? * Yes No If yes, list all past surgical procedures. * Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional). * Do you have any allergies? * Yes No If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects). * Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at All Several Days Over Half of the Days Nearly Every Day Feeling nervous, anxious, or on edge Not at All Several Days Over Half of the Days Nearly Every Day Not being able to stop or control worrying Not at All Several Days Over Half of the Days Nearly Every Day Little interest or pleasure in doing things Not at All Several Days Over Half of the Days Nearly Every Day Feeling down, depressed, or hopeless Not at All Several Days Over Half of the Days Nearly Every Day GENERAL QUESTIONS 1. Do you have any concerns that you would like to discuss with your provider? * Yes No Unsure 1a. If Yes, please explain. * 2. Has a provider ever denied or restricted your participation in sports for any reason? * Yes No Unsure 2a. If Yes, please explain. * 3. Do you have any ongoing medical issues or recent illness? * Yes No Unsure 3a. If Yes, please explain. * HEART HEALTH QUESTIONS ABOUT YOU 4. Have you ever passed out or nearly passed out during or after exercise? * Yes No Unsure 4a. If Yes, please explain. * 5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? * Yes No Unsure 5a. If Yes, please explain. * 6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? * Yes No Unsure 6a. If Yes, please explain. * 7. Has a doctor ever told you that you have any heart problems? * Yes No Unsure 7a. If Yes, please explain. * 8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography. * Yes No Unsure 8a. If Yes, please explain. * 9. Do you get light-headed or feel shorter of breath than your friends during exercise? * Yes No Unsure 9a. If Yes, please explain. * 10. Have you ever had a seizure? * Yes No Unsure 10a. If Yes, please explain. * HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)? * Yes No Unsure 11a. If Yes, please explain. * 12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)? * Yes No Unsure 12a. If Yes, please explain. * 13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35? * Yes No Unsure 13a. If Yes, please explain. * BONE AND JOINT QUESTIONS 14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game? * Yes No Unsure 14a. If Yes, please explain. * 15. Do you have a bone, muscle, ligament, or joint injury that bothers you? * Yes No Unsure 15a. If Yes, please explain. * MEDICAL QUESTIONS 16. Do you cough, wheeze, or have difficulty breathing during or after exercise? * Yes No Unsure 16a. If Yes, please explain. * 17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? * Yes No Unsure 17a. If Yes, please explain. * 18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area? * Yes No Unsure 18a. If Yes, please explain. * 19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)? * Yes No Unsure 19a. If Yes, please explain. * 20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? * Yes No Unsure 20a. If Yes, please explain. * 21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling? * Yes No Unsure 21a. If Yes, please explain. * 22. Have you ever become ill while exercising in the heat? * Yes No Unsure 22a. If Yes, please explain. * 23. Do you or does someone in your family have sickle cell trait or disease? * Yes No Unsure 23a. If Yes, please explain. * 24. Have you ever had or do you have any problems with your eyes or vision? * Yes No Unsure 24a. If Yes, please explain. * 25. Do you worry about your weight? * Yes No Unsure 25a. If Yes, please explain. * 26. Are you trying to or has anyone recommended that you gain or lose weight? * Yes No Unsure 26a. If Yes, please explain. * 27. Are you on a special diet or do you avoid certain types of foods or food groups? * Yes No Unsure 27a. If Yes, please explain. * 28. Have you ever had an eating disorder? * Yes No Unsure 28a. If Yes, please explain. * FEMALES ONLY 29. Have you ever had a menstrual period? * Yes No 30. How old were you when you had your first menstrual period? * 31. When was your most recent menstrual period? * 32. How many periods have you had in the past 12 months? * Signature of Athlete * Clear Signature of Parent/Guardian * Clear ©2023 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. If you are human, leave this field blank. Submit Δ
