VALID FOR SCHOOL YEAR
6 DIGIT STUDENT ID NUMBER
7 PrePhysical Evaluation 2020 7 of 14
Pre-Participation Physical Evaluation – Gahr High School
Student History – Home Phone/Cell ____________________________________ Date of Exam ________________
Name _______________________________________ Sex _____ Age _____ Grade _____ Date of Birth ___________
LAST NAME FIRST NAME
Sport(s) Interested in Participating ____________________________________________________________________
Home Address ____________________________________________ City __________________ Zip Code _________
Personal physician ________________________________________________________________________________
Contact Emergency:
Name ____________________________________ Relationship _____________ Phone (H) ______________ (W) _____________
Explain “YES” answers below:
Circle questions you don’t know the answers to.
1. Have you had a medical illness or Injury since your
last check up or sports physical?
Do you have an ongoing or chronic illness?
2. Have you ever been hospitalized overnight?
Have you ever had surgery?
3. Are you currently taking any prescription or
nonprescription (over-the-counter) medications or pills
or using an inhaler?
Have you ever taken any supplements or vitamins to
help you gain or lose weight or improve your
performance?
4. Do you have any allergies (for example, to pollen,
medicine, food, or stinging insects)?
Have you ever had a rash or hives develop during or
after exercise?
5. Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after
exercise?
Do you get tired more quickly than your friends do
during exercise?
Have you ever had racing of your heart or skipped
heartbeats?
Have you had high blood pressure or high
cholesterol?
Have you ever been told you have a heart murmur?
Has any family member or relative died of heart
problems or of sudden death before age 50?
Have you had a severe viral infection (for example,
myocarditis or mononucleosis) within the last month?
Has a physician ever denied or restricted your
participation in sports for any heart problems?
6. Do you have any current skin problems (for example,
itching, rashes, acne, warts, fungus, or blisters)?
7. Have you ever had a head Injury or concussion?
Have you ever been knocked out, become
unconscious, or lost your memory?
Have you ever had a seizure?
Do you have frequent or sever headaches?
Have you ever had numbness or tingling in your arms,
hands, legs, or feet?
Have you ever had a stinger, burner, or pinched
nerve?
8. Have you ever become ill from exercising in the heat?
9. Do you cough, wheeze, or have trouble breathing
during or after activity?
Do you have asthma?
Do you have seasonal allergies that require medical
treatment?
YES NO
10. Do you use any special protective or corrective
equipment or devices that aren’t usually used for
your sport or position (for example, knee brace,
special neck roll, foot orthotics, retainer on your
teeth, hearing aid)?
11. Have you had any problems with your eyes or
vision?
Do you wear glasses, contacts, or protective
eyewear?
12. Have you ever had a sprain, strain, or swelling
after injury?
Have you broken or fractured any bones or
dislocated any joints?
Have you had any other problems with pain or
swelling in muscles, tendons, bones, or joints?
If yes, check appropriate box and explain below.
Head Elbow Hip
Neck Forearm Thigh
Back Wrist Knee
Chest Hand Shin/calf
Shoulder
13. Do you want to weigh more or less than you do
now?
Do you lose weight regularly to meet weight
requirements for your sport?
14. Do you feel stressed out?
15. Record the dates of your most recent
immunizations (shots) for:
Tetanus _________________ Measles
Hepatitis B _______________ Chickenpox
FEMALES ONLY
16. When was your first menstrual period?
When was your most recent menstrual period?
How much time do you usually have from the
start of one period to the start of another?
How many periods have you had in the last
year?
What was the longest time between periods in
the last year?
Explain “YES” answers here:
YES NO
Upper arm
Finger
Ankle
Foot
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 ___________
2025 - 2026