MSHSAA Preparticipation Physical Forms/Procedure

Revised – April 2023

Page 1 of 5

Medical History Form (Step 1): Issued to Student/Parent(s)/Guardian, Completed by

Student/Parent(s)/Guardian, Taken to Healthcare Professional (MD/DO/ARNP/PA/DC), Retained by Healthcare

Professional.

Note: If the student is under 18 years old, the Medical History questions are to be completed with assistance from

parent(s)/guardian(s).

Note: The health care professional (MD/DO/ARNP/PA/DC) who completes the pre-participation examination (PPE) shall keep this

Medical History form in the patient’s files for their records.

This Medical History form is NOT returned to the school.

MEDICAL HISTORY

Name:

Date of Birth:

Sex assigned at birth (F, M or intersex):

How do you identify your gender? (F, M or other):

List past and current medical conditions:

Have you ever had surgery? 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? If yes, please list all of your allergies (i.e., 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 (Circle response).

Not at All

Several Days

Over Half the Days

Nearly Every Day

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:

A sum of ≥3 is considered positive on either subscale (questions 1 and 2, or questions 3 and 4) for screening purposes.

(Medical History Continued – Next Page)

Revised – April 2023

Page 2 of 5

Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.

GENERAL QUESTIONS

Yes

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

Yes

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 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 ordered 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

Yes

11. Has any family member or relative died of heart problems or

had an unexpected or unexplained sudden death before age

35 (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

Yes

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

Yes

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, had tingling, had 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

Yes

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?

IF “YES,” EXPLAIN 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 Student:

Signature of Parent(s) or Guardian:

Date:

Revised - April - 2023

Page 3 of 5

Preparticipation Physical Examination Form (PPE) (Step 2): Issued to Student/Parent(s)/Guardian, Taken

to Healthcare Professional (MD/DO/ARNP/PA/DC), Retained by Healthcare Professional.

Note: This PPE form is the recommended PPE form intended for guiding the healthcare professional (MD/DO/ARNP/PA/DC) with the

completion of a preparticipation physical evaluation.

Note: The health care professional (MD/DO/ARNP/PA/DC) who completes the pre-participation examination shall keep this PPE form

in the patient’s files for their records. This PPE form is NOT returned to the school.

PRE-PARTICIPATION PHYSICAL EXAMINATION

Name:

Date of Birth:

EXAMINATION

Height:

Weight:

BP: / ( / )

Pulse:

Vision: R 20/ L 20/ Corrected: ☐ Yes ☐ No

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate,

pectus excavatum, arachnodactyly, hyperlaxity,

myopia, mitral valve prolapse (MVP) and aortic

insufficiency)

Eyes, ears, nose and throat

• Pupils equal

• Hearing

Lymph Nodes

Heart*

• Murmurs (auscultation standing, auscultation supine

and +/- Valsalva maneuver)

Lungs

Abdomen

Skin

• Herpes simplex virus (HSV), lesions suggestive of

methicillin-resistant Staphylococcus aureus (MRSA) or

tinea corporis

Neurological

MUSCULOSKELETAL

NORMAL

ABNORMAL FINDINGS

Neck

Back

Shoulder and arm

Elbow and forearm

Wrist, hand and fingers

Hip and thigh

Knee

Leg and ankle

Foot and toes

Functional

• Double-leg squat test, single-leg squat test and box

drop or step drop test

* Consider electrocardiography (ECG), echocardiogram, referral to cardiology for abnormal cardiac history or examination findings, or a combination of those.

Physician Reminders:

Consider additional questions on more-sensitive issues.

• Do you feel stressed out or under a lot of pressure?

• Do you ever feel sad, hopeless, depressed or anxious?

• Do you feel safe at your home or residence?

• Have you ever tried cigarettes, chewing tobacco, snuff or dip?

• During the past 30 days, did you use chewing tobacco, snuff or dip?

• Do you drink alcohol or use any other drugs?

• Have you ever taken anabolic steroids or used any other performance-enhancing supplement?

• Have you ever taken any supplements to help you gain or lose weight or improve your performance?

• Do you wear a seat belt, use a helmet and use condoms?

Revised - April - 2023

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Proceed to next page for

Medical Eligibility Form

Revised - April - 2023

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MSHSAA Medical Eligibility Form (Step 3):

Issued to Student/Parent(s)/Guardian, Taken to/Completed by Healthcare

Professional (MD/DO/ARNP/PA/DC), Copy Retained by Healthcare

Professional, Returned to School Administration.

Note: This Medical Eligibility form is the form to be used by a healthcare professional (MD/DO/ARNP/PA/DC) for granting a medical

release for a student to participate in All Sports – Spirit – Marching Band after the completion of a preparticipation physical

evaluation.

Note: The health care professional (MD/DO/ARNP/PA/DC) must complete this form, retain a copy in the patient’s files for their

records and issue this form to the student/parent.

This Medical Eligibility form MUST be returned to the school.

NAME (Last)

(First)

(Middle Initial)

Date of Birth

Age

Sex assigned at birth (F,M, intersex)

Grade

School

City

Present Address

Telephone

 Medically eligible for all Sports-Spirit-Marching Band without restrictions for two (2) years.

 Medically eligible for all Sports-Spirit-Marching Band without restriction for two (2) years with recommendations for

further evaluation or treatment of: ___________________________________________________________________________

______________________________________________________________________________________________________________________

 Medically eligible for all Sports-Spirit-Marching Band without restriction for less than two (2) years. Specify reasons and

duration of approval: ______________________________________________________________________________________

________________________________________________________________________________________________________

 Medically eligible for certain Sports-Spirit-Marching Band: ____________________________________________________

 NOT medically eligible for Sports-Spirit-Marching Band

 NOT medically eligible pending further evaluation: _________________________________________________________

I have examined the above-named student and completed the pre-participation physical evaluation. Unless otherwise

indicated, the student does not present apparent clinical contraindications to practice and participate in the sport(s) or

activities as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at

the request of the parents. If conditions arise after the student 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 student (and

parents/guardians).

Name of health care professional (Print/Type)

Date of Examination

/ /

Signature of Healthcare Professional (MD/DO/PA/ARNP/DC):

Clinic Address

City

State

Zip

Telephone

Student’s Physician

Student’s Dentist