Name: Jasmine Marie Rayner | DOB: 5/27/2015 | MRN: 71100668 | PCP: Michael E

Albright, MD | Legal Name: Jasmine Marie Rayner

PREPARTICIPATION PHYSICAL EXAMINATION (Interim Guidance)

HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: Jasmine Marie Rayner Date of birth: 5/27/2015
Date of examination: 06/25/2026 Sport(s): Cheerleading
Sex assigned at birth: Female How do you identify your gender? Female
Have you had COVID-19? Yes

Have you been immunized for COVID-19? Yes If yes, have you had: Booster Date(s):
Current COVID-19 Immunizations

No immunizations on file.

List past and current medical conditions: No

Have you ever had surgery? If yes, list all past surgical procedures. No
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbals and
nutritional). No
Do you have any allergies? If yes, please list all your allergies (ie. Medicines, pollens, food, stinging insects). No

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on the edge: Not at all
2. Not being able to stop or control worrying: Not at all
1. Little interest or pleasure in doing things: Several days
2. Feeling down, depressed, or hopeless: Several days
PHQ-4 Interpretation: Normal screening

GENERAL QUESTIONS Yes / No

(Explain "Yes" answers at the end of this form.
1. Do you have any concerns that you would like to discuss with your provider? No
2. Has a provider ever denied or restricted your participation in sports for any reason? No
3. Do you have any ongoing medical issues or recent illness? No
HEART HEALTH QUESTIONS ABOUT YOU Yes / No
4. Have you ever passed out or nearly passed out during or after exercise? No
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during No
exercise?
6. Does your heart ever race, flutter in your chest or skip beats (irregular beats) during No
exercise?
7. Has a doctor ever told you that you have any heart problems? No
8. Has a doctor ever requested a test for your heart? For example, electrocardiography No
(ECG) or echocardiography?
9. Do you get light-headed or feel shorter of breath than your friends during exercise? No
10. Have you ever had a seizure? No
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes / No
11. Has any family member or relative died of heart problems or had an unexpected or No
unexplained sudden death before age 35 years (including drowning or unexplained car
crash)?
12. Does anyone in your family have a genetic heart problem such as hypertrophic No
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? No
 PREPARTICIPATION PHYSICAL EXAMINATION

BONE AND JOINT QUESTIONS Yes / No

14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or No
tendon that caused you to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint injury that bothers you? No
MEDICAL QUESTIONS Yes / No
16. Do you cough, wheeze, or have difficulty breathing during or after exercise? No

17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? No
18. Do you have groin or testicle pain or a painful bulge or hernia in the groin area? No
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or No
methicillin-resistant Staphylococcus aureus (MRSA)?
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, No
or memory problem?
21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been No
unable to move your arms or legs after being hit or falling?
22. Have you ever become ill while exercising in the heat? No
23. Do you or does someone in your family have sickle cell trait or disease? No
24. Have you ever had or do you have any problems with your eyes or vision? No
25. Do you worry about your weight? No
26. Are you trying to or has anyone recommended that you gain or lose weight? No
27. Are you on a special diet or do you avoid certain types of foods or food groups? No
28. Have you ever had an eating disorder? No

FEMALES ONLY Yes / No

29. Have you ever had a menstrual period? No

30. How old were you when you had your first menstrual period? No data recorded
31. When was our most recent menstrual period? No data recorded

32. How many periods have you had in the past 12 months? No data recorded

Explain "Yes" answers here.

No data recorded

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and
correct.

Signature of athlete:________________________________________________________________________________

Signature of parent or guardian:_______________________________________________________________________

Date:__________________
© 2023 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.

Adapted from the 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.
 PREPARTICIPATION PHYSICAL EXAMINATION

PHYSICAL EXAMINATION FORM

Name: Jasmine Marie Rayner Date of Birth: 5/27/2015

PHYSICIAN REMINDERS
1. 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, e-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?
2. Consider reviewing questions on cardiovascular symptoms (Q4–Q13 of History Form).
EXAMINATION
Height: 5' (1.524 m) Weight: 51 kg (112 lb 6.4 oz)
BP: 106/72 Blood pressure %iles are 61% systolic and 86% Pulse: 114
diastolic based on the 2017 AAP Clinical Practice Guideline
. This reading is in the normal blood pressure range.

Visual Acuity Screening Right eye Left eye Both eyes

Without correction: 20/30 20/30 20/30
With correction:
MEDICAL NORMAL ABNORMAL FINDINGS
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus
excavatum, arachnodactyly, hyperlaxity, myopia, mitral valve
prolapse or 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), echocardiography, referral to a cardiologist for abnormal cardiac history or
examination findings, or a combination of those.
Name of health care professional: Michael E Albright, MD Date: 06/25/2026

Signature:
Adapted from 2019 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. Approved for Use Beginning March 2021 by the NCHSSA
 PREPARTICIPATION PHYSICAL EXAMINATION

MEDICAL ELIGIBILITY FORM

Name: Jasmine Marie Rayner

Date of birth: 5/27/2015
Medically eligible for all sports without restriction
Recommendations: none

I have examined the student named on this form and completed the preparticipation physical evaluation. The athlete does
not have
apparent clinical contraindications to practice and can participate in the sport(s) as outlined on this form. A copy of the
physical
examination findings are on record in my office and can be made available to the school at the request of the parents. If
conditions
arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem
is resolved
and the potential consequences are completely explained to the athlete (and parents or guardians).

Name of health care professional: Michael E Albright, MD Date: 06/25/2026

Address: NOVANT HEALTH FORSYTH PEDIATRICS KERNERSVILLE
240 BROAD STREET
KERNERSVILLE NC 27284-2930
Dept: 336-993-8333
Dept Fax: 336-993-5144 Phone: Dept: 336-993-8333

Signature:

SHARED EMERGENCY INFORMATION

Allergies: No Known Allergies
Medications:
Outpatient Encounter Medications as of 6/25/2026:
• acetaminophen (TYLENOL,MAPAP) 160 mg/5 mL liquid, Take 15 mg/kg by mouth every 4 (four) hours as needed for Fever.
• diphenhydrAMINE HCl (BENADRYL PO), Take by mouth as needed.
• ibuprofen (MOTRIN) 100 mg/5 mL oral suspension, Take by mouth every 6 (six) hours as needed for Fever.
• ondansetron (ZOFRAN-ODT) 4 mg disintegrating tablet, Take one tablet (4 mg dose) by mouth every 8 (eight) hours as needed for
Nausea for up to 10 doses.
Other information: none
Emergency contacts: Extended Emergency Contact Information
Primary Emergency Contact: RAMIREZ,ESABELL PETRA
Address: 722 Flynt Street
 KERNERSVILLE, NC 27284 United States of America
Home Phone: 336-528-2219
Mobile Phone: 336-528-2219
Relation: Mother

Adapted from 2019 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. Approved for Use Beginning March 2021 by the NCHSSA

MyChart® licensed from Epic Systems Corporation© 1999 - 2026