IOWA ATHLETIC PRE-PARTICIPATION PHYSICAL EXAMINATION
ARTICLE VII 36.14(1) PHYSICAL EXAMINATION. Every year each student (grades 7-12) shall present to the student’s superintendent a certificate signed by a licensed physician and surgeon, osteopathic physician and surgeon, osteopath, advanced registered nurse practitioner (ARNP), physician’s assistant or qualified doctor of chiropractic, to the effect that the student has been examined and may safely engage in athletic competition. This certificate of physical examination is valid for the purposes of this rule for one (1) calendar year. A grace period, not to exceed thirty (30) days, is allowed for expired certifications of physical examination.
QUESTIONNAIRE FOR ATHLETIC PARTICIPATION (Please type or neatly print this information) Student’s Name 		Male 	Female 			Date of Birth 	Grade	 Home Address (Street, City, Zip) 				School District 			 Parent’s/Guardian’s Name 		Date 				Phone # 			                                          Family Physician 						Phone # 		 
HEALTH HISTORY (The following questions should be completed by the student-athlete with the assistance of a parent or guardian. A parent or guardian is required to sign on the other side of this form after the examination.)

Yes	No	Does this student have / ever had?
 	    	 Allergies to medication, pollen, stinging insects, food, etc.?
 	    	 Any illness lasting more than one (1) week?
 	    	 Asthma or difficulty breathing during exercise?
 	    	 Chronic or recurrent illness or injury?
 	    	 Diabetes?
 	    	 Epilepsy or other seizures?
 	    	 Eyeglasses or contacts?
 	    	 Herpes or MRSA?
 	    	 Hospitalizations (Overnight or longer)?
 	    	 Marfan Syndrome?
 	    	 Missing organ (eye, kidney, testicle)?
 	    	 Mononucleosis or Rheumatic fever?
 	    	 Seizures or frequent headaches?
 	    	 Surgery?
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 	    	 Chest pressure, pain, or tightness with
exercise?
 	    	 Excessive shortness of breath with exercise?
 	    	 Headaches, dizziness or fainting during, or
after, exercise?
 	    	 Heart problems (Racing, skipped beats,
murmur, infection, etc.?)
 	    	 High blood pressure or high cholesterol?
Yes	No	Family History:

Yes	No	Does this student have / ever had?
 	    	 Head injury, concussion, unconsciousness?
 	    	 Headache, memory loss, or confusion with
contact?
 	    	 Numbness, tingling or weakness in arms or
legs with contact?
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 	    	 Severe muscle cramps or illness when
exercising in the heat?
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 	    	 Fracture, stress fracture or dislocated
joint(s)?
 	    	 Injuries requiring medical treatment?
 	    	 Knee injury or surgery?
 	    	 Neck injury?
 	    	 Orthotics, braces, protective equipment?
 	    	 Other serious joint injury?
 	    	 Painful bulge or hernia in the groin area?
 	    	 X-rays, MRI, CT scan, physical therapy?
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 	    	 Has a doctor ever denied or restricted
your participation in sports for any reason?
 	    	 Do you have any concerns you would
like to discuss with your health care provider?

 	    	 Does anyone in your family have Marfan syndrome?
 	    	 Has anyone in your family died of heart problems or any unexpected/unexplained reason before the age of 50?
 	    	 Does anyone in your family have a heart problem, pacemaker or implanted defibrillator?
 	    	 Has anyone in your family had unexplained fainting, seizures, or near drowning?
 	    	 Does anyone in your family have asthma?
 	    	 Do you or someone in your family have sickle cell trait or disease?

Use this space to explain any “YES” answers from above (questions #1-38) or to provide any additional information:

Are you allergic to any prescription or over-the-counter medications? If yes, list:  	
List all medications you are presently taking (including asthma inhalers & EpiPens) and the condition the medication is for:
A. 	B. 	C.  	

Year of last known vaccination:	Tetanus:  	

Meningitis:  	

Influenza:  	

What is the most and least you have weighed in the past year? Most 	Least  	
Are you happy with your current weight? Yes 	No 	If no, how many pounds would you like to lose or gain?

FOR FEMALES ONLY:
How old were you when you had your first menstrual period?  	

Lose  	

Gain  	

How many periods have you had in the last 12 months?  	
Page 1 of 2, Physical Examination Record & Parent’s/Guardian’s Release is on the reverse side

PHYSICAL EXAMINATION RECORD (To be completed by a licensed medical professional as designated in Article VII 36.14(1). This evaluation is only to determine readiness for sports participation. It should NOT be used as a substitute for regular health maintenance examinations.
Athlete’s Name 	Height 	Weight  	

Pulse  	

Blood Pressure 	/	(Repeat, if abnormal 	/	)	Vision R 20/ 	L 20/ 	

NORMAL	ABNORMAL FINDINGS	INITIALS

			

			

			

			

			

Appearance (esp. Marfan’s )
Eyes/Ears/Nose/Throat
Pupil Size (Equal/Unequal)
Mouth & Teeth
Neck
Lymph Nodes
Heart (Standing & Lying)
Pulses (esp. femoral)
Chest & Lungs
Abdomen
Skin
Genitals - Hernia
Musculoskeletal - ROM, strength, etc. (See questions 24-31)
Neurological
Comments regarding abnormal findings:  	

LICENSED MEDICAL PROFESSIONAL’S ATHLETIC PARTICIPATION RECOMMENDATIONS
 	FULL & UNLIMITED PARTICIPATION
 	LIMITED PARTICIPATION - May NOT participate in the following (checked):
 	 Baseball 	Basketball 	Bowling 	Cross Country 	Football 	Golf 	Soccer
 	 Softball	 	Swimming 	Tennis	 	Track	 	Volleyball	 	Wrestling
 	CLEARANCE PENDING DOCUMENTED FOLLOW UP OF 	
 	NOT CLEARED FOR ATHLETIC PARTICIPATION DUE TO	

Licensed Medical Professional’s Name (Printed)	Date of PPE

Licensed Medical Professional’s Signature	Phone

PARENT’S OR GUARDIAN’S PERMISSION AND RELEASE
I hereby verify the accuracy of the information on the opposite side of this form and give my consent for the above named student to engage in approved athletic activities as a representative of his/her school, except those activities indicated above by the licensed professional. I also give my permission for the team’s physician, certified athletic trainer, or other qualified personnel to give first aid treatment to my son or daughter at an athletic event in case of injury.

Name of Parent or Guardian (Printed)	Signature of Parent of Guardian

Address (Street/PO Box, City, State, Zip)	Phone Number
This form has been developed with the assistance of the Committee on Sports Medicine of the Iowa Medical Society and has been approved for use by the Iowa Department of Education, Iowa High School Athletic Association, and Iowa Girls High School Athletic Union. Schools are encouraged NOT to change this form from its published format. Additional school forms can be attached to this form.	9/12