Official Illinois Pre Participation Physical Form in PDF Open Editor

Official Illinois Pre Participation Physical Form in PDF

The Illinois Pre Participation Physical form is a document required for student-athletes before they can participate in sports. This form collects essential health information to ensure that the athlete is physically fit for competition. Parents or guardians must complete it, providing details about the athlete's medical history and current health status.

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The Illinois Pre Participation Physical form is an essential document for student-athletes, ensuring their health and safety before engaging in sports. This form gathers crucial information about the athlete's medical history, including any ongoing conditions, past injuries, and family health history. It covers various topics, such as allergies, heart health, and bone and joint issues, allowing for a comprehensive assessment. Athletes and their parents must fill out the history section before the physical examination. The physical examination itself includes checks on height, weight, vision, and overall physical condition. Additionally, the form addresses specific medical concerns and requires signatures from both the athlete and a parent or guardian, confirming that the information provided is accurate. This process not only safeguards the well-being of the athletes but also helps coaches and schools make informed decisions about participation in sports activities.

Frequently Asked Questions

What is the purpose of the Illinois Pre Participation Physical form?

The Illinois Pre Participation Physical form is designed to assess an athlete's health and fitness before they engage in sports activities. It collects vital information regarding medical history, current health conditions, and any previous injuries. This ensures that athletes can participate safely and helps identify any potential health risks that may require attention.

Who needs to complete the form?

All student-athletes participating in interscholastic sports in Illinois are required to complete the form. This includes students in high school and middle school. Parents or guardians must assist younger athletes in filling out the form to ensure that all relevant medical history and information is accurately reported.

What kind of medical history is required on the form?

The form asks for detailed medical history, including any ongoing medical conditions, past surgeries, hospitalizations, and allergies. Specific questions address heart health, bone and joint issues, and other medical concerns. This information is crucial for medical professionals to evaluate the athlete's readiness for sports participation.

How often must the form be completed?

The Illinois Pre Participation Physical form must be completed annually. This requirement ensures that any changes in the athlete's health or new medical issues are documented and assessed each year. Regular updates help maintain the safety and well-being of student-athletes.

What happens if an athlete has a medical condition?

If an athlete reports a medical condition on the form, a healthcare professional will review the information during the physical examination. Depending on the condition, the athlete may be cleared for participation, may need further evaluation, or may receive restrictions on their activities. The goal is to ensure that athletes can compete safely while managing any health concerns.

Is parental consent required for minors?

Yes, parental consent is mandatory for minors. The form includes sections that require the signatures of both the athlete and a parent or guardian. This consent confirms that parents are aware of their child's participation in sports and the health information being provided.

Form Specifications

Fact Name Fact Description
Purpose The Illinois Pre Participation Physical form is designed to assess the health and fitness of student-athletes before they participate in sports.
Governing Law This form is governed by the Illinois School Code, specifically 105 ILCS 5/22-80.
Completion Requirement It must be completed by either the athlete or their parent prior to the physical examination.
Medical History The form includes a detailed medical history section, which covers allergies, past surgeries, and ongoing medical conditions.
Heart Health Questions Specific questions regarding heart health are included to identify any potential risks associated with sports participation.
Bone and Joint Assessment The form assesses past injuries related to bones, muscles, and joints to ensure athletes are fit for competition.
Female-Specific Questions There are sections specifically for female athletes regarding menstrual health and related concerns.
Consent for Testing High school students must consent to random testing for performance-enhancing substances as part of their participation agreement.

Common mistakes

  1. Failing to provide complete personal information, such as name, birthdate, and address, can lead to delays in processing the form.

  2. Not listing all current medications and supplements can create serious health risks. It's crucial to include both prescription and over-the-counter products.

  3. Overlooking allergies is another common mistake. If there are allergies, they must be clearly identified on the form.

  4. Ignoring past medical history, such as previous surgeries or hospitalizations, can affect the athlete's safety during participation.

  5. Failing to answer the heart health questions accurately can result in undetected risks. It’s essential to respond honestly about any symptoms experienced during exercise.

  6. Not including family history of heart problems can be detrimental. This information helps assess potential genetic risks.

  7. Neglecting to disclose previous injuries or conditions related to bones and joints may lead to inadequate medical evaluations.

  8. Forgetting to mention any ongoing medical conditions can hinder proper assessment. Ensure all conditions, like asthma or diabetes, are documented.

  9. Not signing the form can render it invalid. Both the athlete and a parent or guardian must provide their signatures.

  10. Failing to review the form for accuracy before submission can lead to complications later. Double-check all entries for completeness and correctness.

Form Preview

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

 

 

 

 

 

 

Phone No.

Address

 

 

 

 

 

 

 

 

City/State

 

 

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

 

 

 

Yes

No

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

 

 

 

 

exercise?

 

 

 

 

 

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

 

 

 

Yes

No

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

 

 

 

Yes

No

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

Yes

No

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

Yes

No

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

Pre-participation Examination

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.

 

 

Yes

 

 

 

No

 

Limited

 

 

 

 

 

Examination Date

 

 

Additional Comments:

Ph

si ia

’s Sig ature

 

Ph

si ia

’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

 

Date

 

Signature of parent-guardian

 

Date

Dos and Don'ts

When filling out the Illinois Pre Participation Physical form, it’s important to follow specific guidelines to ensure accuracy and completeness. Here are seven things to do and avoid:

  • Do provide complete and accurate information about your medical history.
  • Do list all medications and allergies, including over-the-counter drugs and supplements.
  • Do answer all questions honestly, especially regarding any past medical conditions or surgeries.
  • Do ensure that both the athlete and parent/guardian sign the form.
  • Don't leave any questions unanswered; if unsure, indicate that you don’t know the answer.
  • Don't rush through the form; take your time to review each section thoroughly.
  • Don't forget to check the date of the physical examination; it must be current for participation.

Documents used along the form

The Illinois Pre Participation Physical form is a crucial document for student-athletes, ensuring their health and safety before engaging in sports activities. In addition to this form, several other documents are often required to provide a comprehensive view of the athlete's medical history and readiness for participation. Below is a list of these important forms.

  • Medical History Form: This document collects detailed information about the athlete's past medical issues, surgeries, and any ongoing health conditions. It helps healthcare providers assess potential risks associated with physical activity.
  • Self-Proving Affidavit: To streamline the probate process, utilize the comprehensive Self-Proving Affidavit template that verifies the authenticity of a will.
  • Insurance Information Form: This form gathers the athlete's insurance details. It is essential for ensuring that any medical expenses incurred during sports activities are covered. This information is crucial in emergencies.
  • Consent for Treatment Form: This document grants permission for medical professionals to provide treatment in case of an injury or health issue during sports. It is a safeguard for both the athlete and the medical staff.
  • Emergency Contact Form: This form lists individuals to contact in case of an emergency. It ensures that the athlete's family or guardians can be reached quickly if needed.

Completing these forms is vital for the safety and well-being of student-athletes. They help ensure that all necessary precautions are taken and that the athlete is in the best possible condition to participate in sports activities.

Misconceptions

Misconceptions about the Illinois Pre Participation Physical form can lead to confusion for athletes and their families. Here are ten common misconceptions explained:

  1. The form is only for high school athletes. Many believe this form is exclusive to high school students. In reality, it applies to all student-athletes participating in organized sports, including middle school.
  2. Only doctors can fill out the form. While a physician's signature is required, other qualified healthcare providers, like nurse practitioners and physician assistants, can also complete the form.
  3. The physical examination is optional. Some think that the physical examination is not necessary. However, it is a requirement for participation in school sports to ensure athlete safety.
  4. All questions must be answered with a "yes" or "no." Many assume that every question must have a definitive answer. It's acceptable to leave questions blank if the athlete does not know the answer.
  5. All athletes pass the examination. It’s a misconception that all athletes will automatically pass. Some may be cleared with limitations, while others may need further evaluation.
  6. The form is only about physical health. Some believe the form only addresses physical conditions. It also includes questions about mental health and family medical history, which are important for overall well-being.
  7. Submitting the form guarantees participation. Just because the form is submitted does not guarantee participation. The final decision rests with the healthcare provider after the examination.
  8. Parents do not need to be involved. Many think that athletes can handle the form alone. Parental involvement is crucial, especially for younger athletes, to ensure all information is accurate.
  9. The form is the same every year. Some believe the form remains unchanged. In fact, it may be updated annually to reflect new health guidelines or recommendations.
  10. Once completed, the form is valid indefinitely. It's a common misconception that the form remains valid for multiple years. Typically, the physical examination must be renewed annually to ensure current health status.