SoFHA
Patient Forms

Sports Physical


Description:

The Kingsport Pediatrics sports physical form.


Code:

13.201

Issued:

07/20/2021

Revision:

1

Revised:

N/A

Patient Information













Insurance







Emergency Contact

















Patient Health Questionnaire

Over the last 2 weeks, how often have you been bother by any of the following problems?



1.
Has a doctor ever denied or restricted your participation in sports for any reason?

2.
Do you have any ongoing medical conditions or recent illness?

3.
Have you ever passed out or nearly passed out DURING or AFTER exercise? ?

4.
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

5.
Does your heart ever race or skip beats (irregular beats) during exercise?

6.
Has a doctor ever told you that you have any heart problems?

7.
Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)

8.
Do you get lightheaded or feel more short of breath than expected during exercise?

9.
Have you ever had a seizure?

10.
Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car accident)?

11.
Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?

12.
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

13.
Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?

14.
Do you have a bone, muscle, ligament, or joint injury that bothers you?

15.
Do you cough, wheeze, or have difficulty breathing during or after exercise?

16.
Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?

17.
Do you have groin or testicle pain or a painful bulge or hernia in the groin area?

18.
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?

19.
Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?

20.
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 falling?

21.
Have you ever become ill while exercising in the heat?

22.
Do you or does someone in your family have sickle cell trait or disease?

23.
Have you ever had or do you have any problems with your eyes or vision?

24.
Do you worry about your weight?

25.
Are your trying to or has anyone recommended that your gain or lose weight?

26.
Are you on a special diet or do you avoid certain types of foods or food groups?

27.
Have you ever had an eating disorder?

28.
Do you have any concerns that you would like to discuss with your provider?

29.
Have you ever had a menstrual period?

30.
How old were you when you had your first menstrual period?

31.
When was your most recent menstrual period?

32.
How many periods have you had in the last 12 months?

You answered "Yes" to the following questions:



When you come into our office, we will require a signature from both the athlete and a parent/guardian.