SoFHA
Patient Forms

Sports Physical

Description:

The Riverside Pediatrics sports physical form.

Code:

2.201

Issued:

08/07/2018

Revision:

Revised:

07/06/2020

Patient Information

NameFirst, MI, Last

Date of Birth

Birth Gender

Gender Identity

Grade

School

Sports

Medical Conditions

Surgery

Medicines

Allergies

Insurance

Insurance Provider

Policy Number

Group Number

Insurance Phone Number

Emergency Contact

Address Line 1

City

Zip Code

Home Phone

Mother's Name

Mother's Cell

Mother's Work Phone

Father's Name

Father's Cell

Father's Work Phone

Other Contact Name

Other Contact Relationship

Other Contact Phone

Patient Health Questionnaire

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

Feeling nervous, anxious, or on edge.

Not At All

Several Days

Over Half The Days

Nearly Every Day

Not being able to stop or control worrying.

Not At All

Several Days

Over Half The Days

Nearly Every Day

Little interest or pleasure in doings things.

Not At All

Several Days

Over Half The Days

Nearly Every Day

Feeling down, depressed, or hopeless.

Not At All

Several Days

Over Half The Days

Nearly Every Day

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

Yes No

Do you have any ongoing medical conditions or recent illness?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

Have you ever had a seizure?

Yes No

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)?

Yes No

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?

Yes No

12.

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

Yes No

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?

Yes No

14.

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

Yes No

15.

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

Yes No

16.

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

Yes No

17.

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

Yes No

18.

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

Yes No

19.

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

Yes No

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?

Yes No

21.

Have you ever become ill while exercising in the heat?

Yes No

22.

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

Yes No

23.

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

Yes No

24.

Do you worry about your weight?

Yes No

25.

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

Yes No

26.

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

Yes No

27.

Have you ever had an eating disorder?

Yes No

28.

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

Yes No

29.

Have you ever had a menstrual period?

Yes No

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:

Please explain the above "Yes" answers below

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