Sports Qualifying Physical Examination Forms

Sports Qualifying Physical Examination Forms

Sports Qualifying Physical Examination Forms

Sports Qualifying Physical Examination Forms

Sports Qualifying Physical Examination Medical Eligibility Form

Sports Qualifying Physical Examination Medical Eligibility Form
2019-2020 SPORTS QUALIFYING PHYSICAL EXAMINATION MEDICAL ELIGIBILITY FORM
Minnesota State High School League
Student Name
Birthdate
Address
Home Telephone
Mobile Telephone
School
Grade
I certify that the above student has been medically evaluated and is deemed medically eligible to: (Select Only One)
Sport Classification Based on Contact
Collision Contact Sports
Limited Contact Sports
Non-contact Sports
Additional recommendations for the school or parents:
I have examined the student named on this form and completed the Sports Qualifying Physical Exam as required by the Minnesota State High School League. The athlete does not have apparent clinical contraindications to practice and participate in the sport(s) as outlined on this form. A copy of the physical examination findings are on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents or guardians).
Print Provider Name
Date of Exam
Office/Clinic Name
Address
Office Telephone
E-Mail Address
IMMUNIZATIONS
[Tdap; meningococcal (MCV4, 2 doses); HPV (3 doses); MMR (2 doses); hep B (3 doses); hep A (2 doses); varicella (2 doses or history of disease); polio (3-4 doses); influenza (annual)]
IMMUNIZATIONS GIVEN TODAY:
EMERGENCY INFORMATION
Allergies
Other Information
Emergency Contact
Relationship
Telephone:
Personal Provider
Office Telephone
This form is valid for 3 calendar years from above date with a normal Annual Health Questionnaire.
FOR SCHOOL ADMINISTRATION USE:
Sports Qualifying Physical History Form
2019-2020 SPORTS QUALIFYING PHYSICAL HISTORY FORM
Minnesota State High School League

Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name
Date of Birth
Date of Examination
Sports
Sex assigned at birth
How do you identify your gender?
Past and current medical conditions:
Have you ever had surgery? If yes, list all past surgeries.
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
Patient Health Questionnaire Version 4 (PHQ-4)
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
GENERAL QUESTIONS
1.Do you have any concerns that you would like to discuss with your provider?
2. Has a provider ever denied or restricted your participation in sports for any reason?
3. Do you have any ongoing medical issues or recent illness?
HEART HEALTH QUESTIONS ABOUT YOU
4. Have you ever passed out or nearly passed out during or after exercise?
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any heart problems?
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
10. Have you ever had a seizure?
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)?
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)?
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?
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?
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?
MEDICAL QUESTIONS
16. Do you cough, wheeze, or have difficulty breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
21. Have you ever had numbness, tingling, weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
22. Have you ever become ill while exercising in the heat?
23. Do you or does someone in your family have sickle cell trait or disease?
24. Have you ever had or do you have any problems with your eyes or vision?
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended that you gain or lose weight?
27. Are you on a special diet or do you avoid certain types of foods or food groups?
28. Have you ever had an eating disorder?
FEMALES ONLY
29. Have you ever had a menstrual period?
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?
Notes

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of Athlete
Signature of parent or guardian
Date
Sports Qualifying Physical Examination Form
2019-2020 SPORTS QUALIFYING PHYSICAL EXAMINATION FORM

Minnesota State High School League
Student Name
Birth Date

Follow-Up Questions About More Sensitive Issues:
1. Do you feel stressed out or under a lot of pressure?
2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days?
3. Do you feel safe?
4. Have you ever tried cigarette, cigar, pipe, e-cigarette smoking, or vaping, even 1 or 2 puffs? Do you currently smoke
5. During the past 30 days, did you use chewing tobacco, snuff, or dip?
6. During the past 30 days, have you had any alcohol drinks, even just one?
7. Have you ever taken steroid pills or shots without a doctor's prescription?
8. Have you ever taken any medications or supplements to help you gain or lose weight or improve your performance?
9. Question “Risk Behaviors” like guns, seatbelts, unprotected sex, domestic violence, drugs, and others.
Notes About Follow-Up Questions:
MEDICAL EXAM
Height
Weight
BMI (optional)
Body fat (optional)
Arm Span
Pulse
BP
Vision: R20/
Vision: L20/
Corrected
Contacts
Hearing: R and L (Audiogram or confrontation)
Appearance
Check any Marfan stigmata present
Initials
HEENT

Eyes
Normal
Abnormal Findings
Initials
Fundoscopic
Normal
Abnormal Findings
Initials
Pupils
Normal
Abnormal Findings
Initials
Hearing
Normal
Abnormal Findings
Initials
Cardiovascular
​​​​​​​
Describe any murmurs present (standing, supine, +/- Valsalva)
Normal
Abnormal Findings
Initials
Pulses (simultaneous femoral & radial)
Normal
Abnormal Findings
Initials
Lungs
Normal
Abnormal Findings
Initials
Abdomen
Normal
Abnormal Findings
Initials
Tanner Staging (optional)
Normal
Stage
Abnormal Findings
Initials
Skin (No HSV, MRSA, Tinea corporis)
Normal
Abnormal Findings
Initials
Musculoskeletal

Neck
Normal
Abnormal Findings
Initials
Back
Normal
Abnormal Findings
Initials
Shoulder/Arm
Normal
Abnormal Findings
Initials
Elbow/Forearm
Normal
Abnormal Findings
Initials
Wrist/Hand/Fingers
Normal
Abnormal Findings
Initials
Hip/Thigh
Normal
Abnormal Findings
Initials
Knee
Normal
Abnormal Findings
Initials
Leg/Ankle
Normal
Abnormal Findings
Initials
Foot/Toes
Normal
Abnormal Findings
Initials
Functional (Double-leg squat test, single-leg squat test, and box drop or step drop test)
Normal
Abnormal Findings
Initials
Additional Notes:
Health Maintenance:
Provider Signature
Date
Athlete With Disabilities Supplement to the Athlete History
Minnesota State High School League

ATHLETE WITH DISABILITIES SUPPLEMENT TO THE ATHLETE HISTORY
Name
Date of Birth
1. Type of disability:
2. Date of disability:
3. Classification (if available):
4. Cause of disability (birth, disease, injury, or other):
5. List the sports you are playing:
6. Do you regularly use a brace, an assistive device, or a prosthetic device for daily activities?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed as having a heat-related or cold-related illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “Yes” answers here.
Please indicate whether you have ever had any of the following conditions:
Atlantoaxial instability
Radiographic (x-ray) evaluation for atlantoaxial instability
Dislocated joints (more than one)
Easy bleeding
Enlarged spleen
Hepatitis
Osteopenia or osteoporosis
Difficulty controlling bowel
Difficulty controlling bladder
Numbness or tingling in arms or hands
Numbness or tingling in legs or feet
Weakness in arms or hands
Weakness in legs or feet
Recent change in coordination
Recent change in ability to walk
Spina bifida
Latex allergy
Explain “Yes” answers here.
I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.
Signature of athlete:
Signature of parent or guardian
Date
PI Adapted Athletics Medical Eligibility Form Addendum
Minnesota State High School League

2019-2020 PI ADAPTED ATHLETICS MEDICAL ELIGIBILITY FORM Addendum

(Use only for Adapted Athletics - PI Division)
The MSHSL has competitive interscholastic Physically Impaired (PI) competition. Students who are deemed fit to participate in competitive athletics from a MSHSL sports qualifying exam should meet the criteria below to participate in Adapted Athletics – PI Division.

The MSHSL Adapted Athletics PI Division program is specifically intended for students with physical impairments who are medically eligible to compete in competitive athletics. A student is administratively eligible to compete in the PI Division with one of the two following criteria:

The student must have a diagnosed and documented impairment specified from one of the two sections below: (Must be diagnosed and documented by a Physician, Physician’s Assistant, and/or Advanced Practice Nurse.)
Neuromuscular
Postural/Skeletal
Traumatic
Growth
Neurological Impairment
Which: affects Motor Function
modifies Gait Patterns
(Optional) Requires the use of prosthesis or mobility device, including but not limited to canes, crutches, walker or wheelchair.
Cardio/Respiratory Impairment that is deemed safe for competitive athletics, but limits the intensity and duration of physical exertion such that sustained activity for over five minutes at 60% of maximum heart rate for age results in physical distress in spite of appropriate management of the health condition.

(NOTE:) A condition that can be appropriately managed with appropriate medications that eliminate physical or health endurance limitations WILL NOT be considered eligible for adapted athletics.
Specific exclusions to PI competition:
The following health conditions, without coexisting physical impairments as outlined above, do not qualify the student to participate in the PI Division even though some of the conditions below may be considered Health Impairments by an individual’s physician, a student’s school, or government agency. This list is not all-inclusive and the conditions are examples of non-qualifying health conditions; other health conditions that are not listed below may also be non-qualifying for participation in the PI Division.

Attention Deficit Disorder (ADD), Attention Deficit Hyperactive Disorder (ADHD), Emotional Behavioral Disorder (EBD), Autism spectrum disorders (including Asperger’s Syndrome), Tourette’s Syndrome, Neurofibromatosis, Asthma, Reactive Airway Disease (RAD), Bronchopulmonary Dysplasia (BPD), Blindness, Deafness, Obesity, Depression, Generalized Anxiety Disorder, Seizure Disorder, or other similar disorders.
Student Name
Provider (PRINT)
Provider (SIGNATURE)
Date of Exam
admin none 7:45 AM - 11:00 AM 2:00 PM - 6:00 PM 2:00 PM - 6:00 PM 7:45 AM - 11:00 AM 2:00 PM - 6:00 PM 2:00 PM - 6:00 PM 6:30 AM - 9:30 AM Closed Closed Chiropractor # # #