This form should be placed into the athlete’s medical file and should not be shared with schools

or sports organizations.

■ PREPARTICIPATION PHYSICAL EVALUATION

HISTORY FORM
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Name: ________________________________________________________________ Date of birth: _____________________________
Jose Delgado 01/23/2007

Date of examination: _______________________________ Sport(s): _____________________________________________________

09/10/2024 Soccer,cross country,tennis,,wrestling,track & field

Sex assigned at birth (F, M, or intersex): _________________ How do you identify your gender? (F, M, or other): ___________________
M M

List past and current medical conditions. _____________________________________________________________________________

None

_______________________________________________________________________________________________________________
Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________
None

_______________________________________________________________________________________________________________
Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and nutritional).
_______________________________________________________________________________________________________________
None

_______________________________________________________________________________________________________________
Do you have any allergies? If yes, please list all your allergies (ie, medicines, pollens, food, stinging insects).
_______________________________________________________________________________________________________________
None

_______________________________________________________________________________________________________________

Patient Health Questionnaire Version 4 (PHQ-4)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.)
Not at all Several days Over half the days Nearly every day
Feeling nervous, anxious, or on edge 0 1 2 3
Not being able to stop or control worrying 0 1 2 3
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)

GENERAL QUESTIONS HEART HEALTH QUESTIONS ABOUT YOU

(Explain “Yes” answers at the end of this form. (CONTINUED ) Yes No
Circle questions if you don’t know the answer.) Yes No 9. Do you get light-headed or feel shorter of breath
1. Do you have any concerns that you would like to than your friends during exercise? X
X
discuss with your provider?
10. Have you ever had a seizure?
2. Has a provider ever denied or restricted your X
X
participation in sports for any reason?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No
3. Do you have any ongoing medical issues or
X 11. Has any family member or relative died of heart
recent illness?
problems or had an unexpected or unexplained
HEART HEALTH QUESTIONS ABOUT YOU Yes No sudden death before age 35 years (including X

4. Have you ever passed out or nearly passed out drowning or unexplained car crash)?
X
during or after exercise?
5. Have you ever had discomfort, pain, tightness, 12. Does anyone in your family have a genetic heart
X problem such as hypertrophic cardiomyopathy
or pressure in your chest during exercise?
(HCM), Marfan syndrome, arrhythmogenic right
6. Does your heart ever race, flutter in your chest, ventricular cardiomyopathy (ARVC), long QT
X X
or skip beats (irregular beats) during exercise? syndrome (LQTS), short QT syndrome (SQTS),
7. Has a doctor ever told you that you have any Brugada syndrome, or catecholaminergic poly-
X
heart problems? morphic ventricular tachycardia (CPVT)?

8. Has a doctor ever requested a test for your

13. Has anyone in your family had a pacemaker or
heart? For example, electrocardiography (ECG)
or echocardiography.
X an implanted defibrillator before age 35? X
 BONE AND JOINT QUESTIONS Yes No MEDICAL QUESTIONS (CONTINUED ) Yes No
14. Have you ever had a stress fracture or an injury 25. Do you worry about your weight? X

to a bone, muscle, ligament, joint, or tendon that X 26. Are you trying to or has anyone recommended
caused you to miss a practice or game? X
that you gain or lose weight?
15. Do you have a bone, muscle, ligament, or joint 27. Are you on a special diet or do you avoid
X X
injury that bothers you? certain types of foods or food groups?
MEDICAL QUESTIONS Yes No 28. Have you ever had an eating disorder? X

16. Do you cough, wheeze, or have difficulty FEMALES ONLY Yes No

X
breathing during or after exercise?
29. Have you ever had a menstrual period?
17. Are you missing a kidney, an eye, a testicle
X 30. How old were you when you had your first
(males), your spleen, or any other organ?
menstrual period?
18. Do you have groin or testicle pain or a painful
X 31. When was your most recent menstrual period?
bulge or hernia in the groin area?
32. How many periods have you had in the past 12
19. Do you have any recurring skin rashes or
months?
rashes that come and go, including herpes or
methicillin-resistant Staphylococcus aureus
X
Explain “Yes” answers here.
(MRSA)?
______________________________________________________
20. Have you had a concussion or head injury that ______________________________________________________
14. Fractured pelvis in 2022

caused confusion, a prolonged headache, or X ______________________________________________________

memory problems?
______________________________________________________
21. Have you ever had numbness, had tingling, had
weakness in your arms or legs, or been unable
______________________________________________________
to move your arms or legs after being hit or
X ______________________________________________________
24 wears glasses for astigmatism

falling? ______________________________________________________
22. Have you ever become ill while exercising in the ______________________________________________________
X
heat? ______________________________________________________
23. Do you or does someone in your family have ______________________________________________________
X
sickle cell trait or disease? ______________________________________________________
24. Have you ever had or do you have any prob- ______________________________________________________
X
lems with your eyes or vision? ______________________________________________________

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: ________________________________________________________
09/10/2024

© 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, educa-
tional purposes with acknowledgment.
 This form should be placed into the athlete’s medical file and should not be shared with schools or sports organizations.

■ PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORM
Name: _________________________________________________________________
Jose Delgado
Date of birth: ____________________________
01/23/2007

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’ 8”
Weight: 187

BP: 90
/ 120
( / ) Pulse: 86
Vision: R 20/ 30
L 20/ 60
Corrected: □ Y □ N X

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance
• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, hyperlaxity, X
myopia, mitral valve prolapse [MVP], and aortic insufficiency)
Eyes, ears, nose, and throat
• Pupils equal X
• Hearing
Lymph nodes X

Heart a
X
• Murmurs (auscultation standing, auscultation supine, and ± Valsalva maneuver)
Lungs X

Abdomen X

Skin
• Herpes simplex virus (HSV), lesions suggestive of methicillin-resistant Staphylococcus aureus (MRSA), or X

tinea corporis
Neurological X

MUSCULOSKELETAL NORMAL ABNORMAL FINDINGS

Neck X

Back X

Shoulder and arm X

Elbow and forearm X

Wrist, hand, and fingers X

Hip and thigh X

Knee X

Leg and ankle X

Foot and toes X

Functional
X
• Double-leg squat test, single-leg squat test, and box drop or step drop test
a
Consider electrocardiography (ECG), echocardiography, referral to a cardiologist for abnormal cardiac history or examination findings, or a combi-
nation of those.
Name of health care professional (print or type): ___________________________________________________ Date: ___________________
SoCal Pediatrics 09/10/2024

Address: ________________________________________________________________________ Phone: ___________________________

1818 N Orangegrove Pomona, Ca 91767 9096226433

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

© 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, educa-
tional purposes with acknowledgment.
 The Medical Eligibility Form is the only form that should be submitted to a school or sports organization.

■ PREPARTICIPATION PHYSICAL EVALUATION

MEDICAL ELIGIBILITY FORM

Name: _______________________________________________________
Jose Delgado
Date of birth: _________________________
01/23/2007

□ Medically eligible for all sports without restriction

X

□ Medically eligible for all sports without restriction with recommendations for further evaluation or treatment of

__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Medically eligible for certain sports

__________________________________________________________________________________________________
__________________________________________________________________________________________________
□ Not medically eligible pending further evaluation

□ Not medically eligible for any sports

Recommendations: ___________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________

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 (print or type): __________________________________________

SoCal Pediatrics
Date: ____________________________
09/10/2024

Address: _________________________________________________________________________
1818 N Orangegrove Pomona, Ca 91767
Phone: ___________________________
9096226433

Signature of health care professional: _____________________________________________________________________, MD, DO, NP, or PA

SHARED EMERGENCY INFORMATION

Allergies: ____________________________________________________________________________________________
None

__________________________________________________________________________________________________
__________________________________________________________________________________________________

Medications: ________________________________________________________________________________________

__________________________________________________________________________________________________
None

__________________________________________________________________________________________________

Other information: ____________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________
Emergency contacts: ___________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

© 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, educa-
tional purposes with acknowledgment.