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Blank Illinois Pre Participation Physical PDF Form

The Illinois Pre Participation Physical form is a crucial document designed for student-athletes to ensure their health and safety before engaging in sports activities. This form must be completed by the athlete or their parent prior to a physical examination, providing essential medical history and current health status. To get started on ensuring a safe sports experience, fill out the form by clicking the button below.

Article Guide

The Illinois Pre Participation Physical form plays a crucial role in ensuring the health and safety of student-athletes before they engage in sports. This comprehensive document collects essential information about the athlete's medical history, current health status, and any potential risks associated with participation in physical activities. It begins with basic identification details, such as the athlete's name, birthdate, and school year, followed by a series of questions designed to assess any existing medical conditions, allergies, and past injuries. Specific sections delve into heart health, asking about family history of heart problems and any previous episodes of discomfort during exercise. Additionally, the form addresses bone and joint health, inquiring about past injuries and the use of assistive devices. Medical questions cover a wide range of topics, including respiratory issues, vision problems, and concerns related to weight or diet. For female athletes, there are specific inquiries regarding menstrual health. After completing the history section, a physical examination is conducted, where a healthcare professional evaluates the athlete's overall health. Finally, the form includes a section on consent for random drug testing, underscoring the importance of fair play in athletics. This thorough process not only safeguards the well-being of young athletes but also helps schools and parents make informed decisions about their participation in sports.

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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

➤ PDF File

Form Specifications

Fact Name	Details
Purpose	The Illinois Pre-Participation Physical form is designed to assess an athlete's health and fitness before engaging in sports.
Required Information	It requires personal information such as name, birthdate, and medical history, including allergies and past injuries.
Medical History	Questions cover various health concerns, including heart health, bone and joint issues, and general medical conditions.
Family History	The form includes inquiries about family health history related to heart problems and other significant medical conditions.
Physical Examination	A physical examination is required, assessing vital signs, musculoskeletal health, and overall appearance.
Governing Law	The form is governed by the Illinois School Code, specifically Section 27-23.1, which mandates physical examinations for student-athletes.
Consent for Testing	For high school students, consent for random testing for performance-enhancing substances is included in the form.
Signature Requirement	Both the athlete and a parent or guardian must sign the form, affirming the accuracy of the information provided.
Confidentiality	Results of any testing will be kept confidential, as required by law, ensuring the privacy of the athlete.

Illinois Pre Participation Physical: Usage Guidelines

Filling out the Illinois Pre Participation Physical form is an important step for athletes before they can participate in sports. This form gathers essential information about the athlete's health history and current medical conditions. Following these steps will help ensure that you complete the form accurately and thoroughly.

Begin by writing the athlete's name in the appropriate fields: last name, first name, and middle name.
Fill in the address, including city and state, along with a contact phone number.
Provide the athlete's birthdate, age, and class.
Enter the student ID number.
Write the parent's name and their contact phone number.
Fill in the parent's address, including city and state.
List all current medicines and supplements the athlete is taking.
Indicate if the athlete has any allergies and specify the type.
Answer the general questions by marking "Yes" or "No" as applicable.
Complete the heart health questions about the athlete.
Answer the bone and joint questions accurately.
Respond to the medical questions listed.
If applicable, complete the females only section regarding menstrual history.
Sign the form to confirm that the information provided is complete and correct.
Ensure the parent or guardian also signs the form.
Finally, include the date of completion.

Once you have filled out the form, it is essential to submit it to the appropriate school official or healthcare provider. They will review the information and may schedule a physical examination to ensure the athlete is fit to participate in sports activities.

Your Questions, Answered

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

The Illinois Pre Participation Physical form is designed to ensure that student-athletes are medically cleared to participate in sports. This form collects important health information about the athlete, including their medical history, any ongoing conditions, and family health issues. By gathering this information, the form helps identify any potential risks or concerns that could affect the athlete's safety during sports activities.

Who needs to complete the Illinois Pre Participation Physical form?

All student-athletes participating in Illinois high school sports are required to complete this form. It must be filled out by either the athlete or their parent or guardian before the athlete undergoes a physical examination. This ensures that all relevant health information is considered during the medical evaluation, which is crucial for the athlete's safety and well-being.

What should I do if I have concerns about my child's health when completing the form?

If you have any concerns regarding your child's health, it is essential to communicate these when filling out the form. Be honest and thorough in answering the questions, especially those related to medical history and current health conditions. If necessary, consult with a healthcare professional before submitting the form. This proactive approach can help ensure that your child receives the appropriate care and attention they may need during their athletic participation.

What happens after the form is submitted?

Once the Illinois Pre Participation Physical form is completed and submitted, it will be reviewed by a qualified healthcare provider during the physical examination. The provider will assess the athlete's health based on the information provided. If any concerns arise, the healthcare provider may recommend further evaluation or restrictions on participation. If everything is in order, the athlete will receive clearance to participate in sports for the upcoming year.

Common mistakes

Incomplete Personal Information: Many individuals forget to fill out all personal details, such as the full name, birthdate, and contact information. This can lead to delays or issues with processing the form.
Omitting Medical History: Some parents or athletes neglect to provide a complete medical history. Missing information about past injuries, surgeries, or medical conditions can result in safety concerns during physical activities.
Ignoring Allergy Information: Failing to list all allergies or medications can have serious consequences. It’s crucial to disclose any allergies, especially to medications or food, to ensure the athlete’s safety.
Not Consulting a Doctor: Some individuals may skip the physical examination altogether or not consult a doctor for their health concerns. This can lead to overlooking important health issues that could affect athletic performance.
Rushing the Form: Filling out the form in a hurry can lead to mistakes. Taking the time to carefully read and answer each question ensures accuracy and completeness, which is vital for the athlete's well-being.

Documents used along the form

When preparing for participation in sports, the Illinois Pre Participation Physical form is just one of several important documents that may be required. Each of these documents serves a unique purpose, ensuring that athletes are fit to compete and that their health and safety are prioritized. Below is a list of other commonly used forms and documents associated with the pre-participation process.

Medical History Form: This form collects detailed information about the athlete's past medical conditions, surgeries, and any family history of health issues. It helps healthcare providers assess potential risks.
Emergency Contact Form: This document lists individuals who should be contacted in case of an emergency. It includes names, phone numbers, and relationships to the athlete.
Consent for Treatment Form: Parents or guardians sign this form to give permission for medical treatment in case of injury or illness during sports activities.
Insurance Information Form: This form collects details about the athlete's health insurance coverage, including policy numbers and provider contact information. It ensures that medical expenses can be addressed if necessary.
Concussion Awareness Form: Athletes and their parents review this document, which outlines the signs and symptoms of concussions. Acknowledgment of understanding is often required.
Waiver of Liability Form: This document releases the school or organization from liability in case of injury. It is crucial for protecting the institution from legal claims.
Physical Examination Record: This form is completed by a physician during the physical exam. It documents the findings and confirms that the athlete is cleared for participation.
Steroid Testing Policy Consent Form: Required for high school athletes, this form indicates the student's agreement to comply with testing for performance-enhancing substances.

Each of these forms plays a vital role in ensuring the health and safety of student-athletes. Completing them accurately and thoroughly helps protect both the athlete and the school, promoting a safe sporting environment.

Similar forms

The Illinois Pre Participation Physical form is essential for ensuring that student-athletes are medically fit to participate in sports. Several other documents serve similar purposes, focusing on health assessments and medical history. Below are eight documents that share similarities with the Illinois Pre Participation Physical form:

Sports Physical Form: This document is often required by schools and sports organizations to assess an athlete's health before they can participate in sports. Like the Illinois form, it collects medical history and current health status.
Health History Questionnaire: This form gathers detailed information about an individual's past medical conditions, surgeries, and family health history. It is similar in that it aims to identify any potential health risks before engaging in physical activities.
Emergency Contact Form: While primarily focused on providing emergency contacts, it often includes medical information that can be crucial during emergencies. This aligns with the Illinois form's goal of ensuring the athlete's safety.
Immunization Records: These records document vaccinations and are sometimes required for participation in school sports. They ensure that athletes are protected against contagious diseases, similar to how the physical form checks for overall health.
Medical Release Form: This document allows healthcare providers to share medical information with schools or sports teams. It complements the Illinois form by ensuring that all relevant health information is accessible when needed.
Concussion Management Plan: This plan outlines procedures for handling concussions in athletes. It is similar in its focus on health and safety, ensuring that athletes receive proper care in case of head injuries.
Parental Consent Form: This document requires parental permission for a child to participate in sports. It often includes a section for disclosing any known medical issues, paralleling the Illinois form's emphasis on medical history.
Physical Therapy Evaluation Form: This form is used when an athlete has undergone physical therapy. It assesses recovery and readiness to return to sports, much like the Illinois form evaluates fitness for participation.

These documents collectively contribute to a comprehensive understanding of an athlete's health, ensuring their safety and well-being during sports participation.

Dos and Don'ts

Filling out the Illinois Pre Participation Physical form is a crucial step for student-athletes. To ensure accuracy and compliance, here are ten essential dos and don'ts to keep in mind.

Do provide complete and accurate information about your medical history.
Do list all medications, including over-the-counter and supplements.
Do check for allergies and specify them clearly.
Do answer all general and heart health questions honestly.
Do consult with a doctor if unsure about any health condition.

Don't leave any questions unanswered; this can delay the process.
Don't exaggerate or downplay symptoms; honesty is key.
Don't forget to include family medical history; it’s vital for assessment.
Don't submit the form without a parent or guardian’s signature if required.
Don't overlook the importance of keeping a copy for your records.

By following these guidelines, you can help ensure a smooth and effective evaluation process. Your health and safety come first, so take this step seriously!

Misconceptions

Understanding the Illinois Pre Participation Physical form is essential for athletes and their families. However, several misconceptions often arise. Here are eight common misunderstandings:

Only athletes with health issues need to fill it out. All student-athletes must complete the form, regardless of their health status. This ensures that everyone is assessed for safety.
Parents should not be involved in the process. Parents play a crucial role. They must provide accurate medical histories and sign the form, ensuring that all information is complete.
The physical examination is just a formality. The examination is a vital step in identifying potential health issues that could affect an athlete’s performance and safety.
All questions on the form are optional. Every question must be answered to the best of the athlete's and parent's knowledge. Incomplete forms can delay participation.
Once submitted, the form does not need to be updated. If a student’s health changes, such as a new injury or condition, the form should be updated to reflect this information.
It’s only necessary for high school athletes. The form is required for all students participating in sports, regardless of their grade level.
Only physical health is assessed. The form also addresses mental health and other medical conditions, ensuring a comprehensive evaluation of the athlete.
Results from the physical are private and cannot be shared. While the results are confidential, they may be shared with school officials as necessary for safety and compliance with regulations.

Being informed about these misconceptions can help ensure a smoother experience for athletes and their families as they navigate the pre-participation process.

Key takeaways

Complete the Form Accurately: Ensure that all sections of the Illinois Pre Participation Physical form are filled out completely. This includes personal information, medical history, and any medications or allergies. Inaccurate or incomplete information could delay the approval for participation in sports.
Consult with a Doctor: Schedule a physical examination with a healthcare provider. This examination is crucial to assess the athlete's health and readiness for sports. The doctor will review the completed form and conduct necessary tests, if needed.
Understand the Importance of Medical History: Be honest about any past medical issues, including surgeries, injuries, or family health history. This information is vital for identifying potential risks and ensuring the athlete's safety during sports activities.
Stay Informed on Policies: Familiarize yourself with the IHSA Steroid Testing Policy and other relevant regulations. Understanding these policies is essential for compliance and to avoid penalties related to performance-enhancing substances.