Fill in a Valid Illinois Pre Participation Physical Template

The Illinois Pre Participation Physical form serves as a crucial document required for student-athletes before they engage in sports activities. This form gathers important medical history and health information to ensure the safety and well-being of young athletes. Completing this process is essential, so please remember to fill out the form by clicking the button below.

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The Illinois Pre Participation Physical form plays a crucial role in ensuring the health and safety of student-athletes. This form addresses various aspects of an athlete's medical history and current status before they engage in any sporting activities. Athletes or their parents must fill out important details such as personal information, medical history, and specific questions related to heart health, bones, joints, and any other medical concerns. It assesses the athlete's use of medications, any allergies, and previous hospitalizations or surgeries. The form also looks at family medical history to identify any potential hereditary issues related to heart problems or other conditions. Ultimately, this thorough examination ensures that all athletes are fit to participate and helps prevent injuries or health complications during sports. Examination results are documented by a medical professional, who evaluates the athlete's physical condition and verifies if they can participate in sports, making this process vital for both school and physical health.

Illinois Pre Participation Physical Example

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

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

(

)

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

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

Click for Illinois Pre Participation Physical File

File Breakdown

Fact Name	Detail
Purpose	The Illinois Pre Participation Physical form is required to assess an athlete's fitness to participate in school sports.
Completing Entity	The form must be filled out either by the athlete or by a parent or guardian prior to the physical examination.
Age Requirement	It is necessary for all student-athletes, regardless of age, to complete this form before participating in school sports.
Medical History Disclosure	The form includes a section that requires disclosure of any ongoing medical conditions, allergies, or previous injuries.
Heart Health Questions	There are specific questions related to heart health to identify any potential cardiac issues that may affect participation.
Family Medical History	The form asks for a family medical history concerning heart problems and other serious health issues.
Bone and Joint Assessment	It includes questions aimed at assessing any past injuries to bones and joints that could hinder athletic performance.
Confidentiality Assurance	Results and information shared on the form are confidential, protected under relevant laws.
Regulatory Basis	The form is governed by the Illinois School Code, specifically for student athletics within the Illinois High School Association (IHSA).
Signature Requirement	Both a student-athlete's and a parent’s signature are required to confirm the accuracy of the information provided on the form.

Guide to Using Illinois Pre Participation Physical

Completing the Illinois Pre-Participation Physical form is an important task that helps ensure the safety and well-being of student-athletes. This step-by-step guide will assist you through the process. Make sure you have all necessary information handy before you begin.

Fill in Personal Information: Start by entering the athlete's name, school year, and contact information, including address and phone number.
Record Birthdate and Age: Write down the athlete's birthdate and age accurately, as this information is crucial for identification purposes.
Student ID Number: If applicable, include the student ID number in the designated space.
Parent/Guardian Information: Provide the parent's or guardian's name, phone number, and address. This helps the medical staff contact them if necessary.
List Medications and Allergies: Detail any prescription and over-the-counter medications the athlete is currently taking. Indicate whether the athlete has any allergies and specify them.
Answer General Questions: Respond truthfully to the series of "Yes" or "No" questions regarding the athlete's medical history and current health status.
Heart Health Questions: Record responses to questions specifically concerning heart health for both the athlete and their family. This information is critical for preventing any potential issues during athletic activities.
Bones and Joints Questions: Proceed to answer questions regarding any past injuries or conditions related to bones and joints.
Medical Symptom Questions: Complete the section addressing symptoms that may affect the athlete’s ability to participate, such as breathing issues or previous concussions.
Female-Specific Questions: If applicable, answer the questions intended specifically for females regarding menstrual history.
Sign and Date: Ensure that both the athlete and the parent or guardian sign the form, confirming that all provided information is accurate and complete.

Once the form is filled out, it must be submitted to the appropriate school or athletic office. They will review it and keep it on file to ensure a smooth and safe sports participation experience. Be sure to retain a copy for your records as well.

Get Answers on Illinois Pre Participation Physical

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

The Illinois Pre Participation Physical form is designed to gather important medical information about an athlete before they engage in sports activities. It ensures that the athlete is physically fit and helps identify any health concerns that could impact their performance or safety during sports.

Who is required to complete the form?

All students intending to participate in athletics within Illinois schools must complete this form. It is an essential step for athletes at every level to ensure they are healthy enough for physical activity.

What information is collected on the form?

The form collects personal information such as the athlete's name, school, birthdate, and contact details. Additionally, it includes a medical history section where athletes or their parents must disclose current medications, allergies, ongoing medical conditions, as well as any previous injuries or surgeries.

How does the physical examination section work?

The physical examination section requires a healthcare professional to assess the athlete's physical condition. The doctor will check various health indicators, including height, weight, heart health, vision, and any musculoskeletal issues. The findings will determine whether the athlete is cleared for participation.

What happens if the form is incomplete or not filled out accurately?

If the form is incomplete or contains inaccuracies, it may delay the athlete's eligibility to participate in sports. It is crucial to provide complete and truthful information to avoid potential complications and ensure the athlete's health is appropriately managed.

How often must the form be completed?

The form must be completed each academic year. This annual requirement ensures that any changes in the athlete’s health status are documented and assessed by a qualified healthcare provider before participation in sports.

What should be done if an athlete has a pre-existing medical condition?

If an athlete has a pre-existing medical condition, it is vital to disclose this on the form. This enables healthcare providers to assess the risks involved with sports participation and provide necessary recommendations or limitations to safeguard the athlete's health.

Are there any specific requirements for athletes with disabilities?

Yes, athletes with disabilities may have additional considerations. They should consult with their healthcare provider and include relevant information on the form so that necessary accommodations can be made for their participation in sports.

Where can the completed form be submitted?

The completed form should be submitted to the athlete's school or the athletic department. It is recommended to keep a copy for personal records before submission.

Common mistakes

Filling out the Illinois Pre Participation Physical form accurately is essential for the health and safety of student-athletes. Unfortunately, mistakes occur often. One common error involves the omission of important medical history. Parents may forget to mention a chronic condition or previous surgeries which can lead to serious health risks during physical activities.

Another frequent mistake is failing to list all medications and allergies. Athletes might take over-the-counter medications or supplements that could interfere with treatment during emergencies. If a student has allergies, neglecting to indicate them may result in dangerous situations.

People often answer questions hastily, not fully understanding what each question means. Rushing through sections like Heart Health or Bone and Joint Questions can lead to incomplete answers. Underlying conditions might go unnoticed, placing athletes at risk during exertion.

When it comes to family medical history, many individuals either don’t know or fail to include vital information. A family history of heart problems, for instance, is crucial for medical personnel to understand. Skipping this information may result in a lack of necessary precautions.

Parents sometimes neglect to sign the form or forget to provide their contact information. This oversight can hinder communication between health professionals and the family, especially during emergencies. The presence of accurate and accessible contact details is crucial.

Filling in the fields correctly is also essential. Mistakes in names, dates of birth, or student ID numbers can cause administrative issues that delay participation in sports. Double-checking these items ensures a smoother process.

Lastly, failing to clarify "Yes" answers can create problems. If an athlete answers "yes" to questions about previous injuries or hospitalizations, it’s important to provide detailed explanations where prompted. Neglecting to do so might mean medical professionals miss critical pieces of information needed to assess the athlete's fitness for participation.

Documents used along the form

The Illinois Pre Participation Physical form is a vital document for students intending to engage in athletic activities. In addition to this form, several other documents often accompany it to ensure the safety and health of young athletes. Below are four such documents that play an essential role in the pre-participation process.

Concussion Information Sheet: This document provides important information about the signs and symptoms of a concussion. Athletes and their parents are encouraged to review this information to foster understanding and recognition of this serious injury.
Emergency Contact Form: This form collects essential information about who to contact in case of an emergency. It typically includes names, phone numbers, and relationships to the student, ensuring that the school can reach family or guardians swiftly if needed.
Medical History Form: This form allows for a comprehensive overview of the athlete's medical past. It may include details about previous injuries, surgeries, or ongoing health issues, ensuring that coaches and medical personnel are aware of any considerations needed during practices and games.
Assumption of Risk and Waiver: This document informs athletes and their parents of the inherent risks involved in sports participation. By signing this waiver, they acknowledge those risks and agree not to hold the school liable for injuries that may occur while participating in athletic activities.

These forms collectively help schools maintain the health and safety of student-athletes. Proper completion and review of these documents can significantly impact the athlete's experience and well-being in sports.

Similar forms

The Illinois Pre Participation Physical form shares similarities with several other important documents that also focus on health assessments for sports participation and medical evaluations. Below is a list of seven documents that share features with the Illinois form:

Athlete Health Questionnaire: This document gathers health information from athletes, including medical history and current health concerns, much like the Illinois form's comprehensive history section.
Sports Physical Form: Similar to the Illinois form, this document is used to assess a student-athlete's readiness for physical activity, covering vital signs and medical history.
Emergency Contact Form: This form complements the physical assessment by ensuring that emergency contacts are readily available, addressing safety during sports activities.
Waiver and Release Form: Like the Illinois form, it requires parents and athletes to acknowledge potential risks associated with sports participation, promoting informed consent.
Concussion Management Policy: This document is related to the Illinois form as it outlines protocols for handling concussion-related health issues in athletes.
Immunization Records: Immunization details are often required alongside sports physicals, similar to how the Illinois form verifies health history and ensures athlete wellness.
Medications and Allergies Form: This form parallels the Illinois document by collecting essential information on any medications and allergies that could affect an athlete’s participation in sports.

Dos and Don'ts

Filling out the Illinois Pre Participation Physical form is an important task that requires careful attention. Here is a list of things you should and shouldn't do to ensure a smooth process.

Do provide accurate information. Your answers should reflect your current health status and medical history. Inaccurate information can lead to serious consequences.
Do discuss any ongoing health issues with your physician. If there are any concerns related to sports involvement, it’s crucial to address them.
Do list all medications and allergies. This includes prescription and over-the-counter medicines as well as any allergies you may have.
Do ask for clarification if unsure. If you don’t understand a question, don’t hesitate to ask for help to ensure your answers are correct.
Don’t skip any questions. Each question is designed to gather necessary information about your health.
Don’t exaggerate or minimize symptoms. Be honest about your experiences to avoid complications when participating in sports.
Don’t fill out the form alone if you're a minor. Parents or guardians should assist in the process to make sure all aspects are covered.
Don’t forget to sign and date the form. All required signatures are necessary to validate the document and proceed with the examination.

Misconceptions

Here are ten common misconceptions about the Illinois Pre Participation Physical form:

It is only for high school athletes. The form is also required for middle school athletes participating in sports.
It must be filled out by a doctor. Parents or guardians can assist in completing the history section before the examination.
Students won’t be allowed to participate if there are any “yes” answers. Yes answers may require further evaluation, but they do not automatically disqualify a student.
All medical conditions need to be disclosed. Only current and significant medical conditions that may affect sports participation need to be mentioned.
The physical exam is optional. The exam is a mandatory requirement for all student-athletes to ensure their safety.
Once completed, the form does not need updating. Athletes must submit a new form each year or when their health status changes.
Only physical injuries need to be reported. The form asks about general health, including mental and emotional well-being.
Your child can participate without submitting this form. Schools will not allow participation in sports until the completed form is submitted.
It is sufficient to just ask the doctor to sign the form. Complete answers in the history section are vital for proper evaluation.
Parents can skip the section about the family medical history. Family history is essential to identify any potential hereditary health issues.

Understanding these misconceptions can help ensure a smoother process for student-athletes and their families.

Key takeaways

Filling out the Illinois Pre Participation Physical form is a crucial step for athletes preparing to participate in school sports. Understanding the requirements and intentions behind this form helps ensure the safety and well-being of young athletes. Here are some key takeaways:

The form must be completed by either the athlete or a parent or guardian before the physical examination takes place.
Accurate information regarding current medications and allergies is essential. This can prevent potential health risks during athletic activities.
Specific health history questions cover various topics, including prior injuries, surgeries, and family medical history. Honest responses will allow healthcare providers to make informed decisions regarding fitness for participation.
Heart health is a significant focus. Questions address any previous heart-related issues, which are vital for ensuring safe participation in sports.
The physical examination section will be filled out by a healthcare provider. They will check for physical conditions that could impact athletic performance and safety.
Parental consent for steroid testing is required, specifically for high school athletes. Awareness of the IHSA's policy on performance-enhancing drugs is crucial for maintaining fair play.

By understanding these key points, athletes and their families can navigate the process more effectively, leading to a safer sports experience.