SchoolSportsPreParticipationExaminationPart1:StudentorParentCompletes

NAME: BIRTHDATE:

RevisedMay2010

ADDRESS: PHONE:( ) AthleteandParent/Guardian:Pleasereviewallquestionsandanswerthemtothebestofyourability.ExplainanyYESanswersonback. MedicalProvider:Pleasereviewwiththeathletedetailsofanypositiveanswers.

YESNODontKnow

1. 2. 3. 4. 5. 6. 7. 8. 9.

Hasanyoneintheathletesfamilydiedsuddenlybeforetheageof50years? Hastheathleteeverpassedoutduringexerciseorstoppedexercisingbecauseofdizzinessorchestpain? Doestheathletehaveasthma(wheezing),hayfever,otherallergies,orcarryanEPIpen? Istheathleteallergictoanymedicationsorbeestings? Hastheathleteeverbrokenabone,hadtowearacast,orhadaninjurytoanyjoint? Hastheathleteeverhadaheadinjuryorconcussion? Hastheathleteeverhadahitorblowtotheheadthatcausedconfusion,memoryproblems,orprolongedheadache? Hastheathleteeversufferedaheatrelatedillness(heatstroke)? Doestheathletehaveachronicillnessorseeaphysicianregularlyforanyparticularproblem?

10. Doestheathletetakeanyprescribedmedicine,herbsornutritionalsupplements? 11. Doestheathletehaveonlyoneofanypairedorgan(eyes,kidneys,testicles,ovaries,etc.)? 12. Hastheathleteeverhadpriorlimitationfromsportsparticipation? 13. Hastheathletehadanyepisodesofshortnessofbreath,palpitations,historyofrheumaticfeverortiringeasily? 14. Hastheathleteeverbeendiagnosedwithaheartmurmurorheartconditionorhypertension? 15. Isthereahistoryofyoungpeopleintheathletesfamilywhohavehadcongenitalorotherheartdisease:cardiomyopathy,abnormal heartrhythms,longQTorMarfan'ssyndrome?(Youmaywrite"Idon'tunderstandtheseterms"andinitialthisitem,ifappropriate.) 16. Hastheathleteeverbeenhospitalizedovernightorhadsurgery? 17. Doestheathleteloseweightregularlytomeettherequirementsforyoursport? 18. Doestheathletehaveanythingheorshewantstodiscusswiththephysician? 19. Doestheathletecough,wheeze,orhavetroublebreathingduringorafteractivity? 20. Areyouunhappywithyourweight? 21. FEMALESONLY a. b. c. Whenwasyourfirstmenstrualperiod? Whenwasyourmostrecentmenstrualperiod? Whatwasthelongesttimebetweenmenstrualperiodsinthelastyear?

Parent/GuardiansStatement: Ihavereviewedandansweredthequestionsabovetothebestofmyability.Iandmychildunderstandandacceptthattherearerisksofseriousinjuryanddeathin anysport,includingtheone(s)inwhichmychildhaschosentoparticipate.Iherebygivepermissionformychildtoparticipateinsports/activities. Iherebyauthorizeemergencymedicaltreatmentand/ortransportationtoamedicalfacilityforanyinjuryorillnessdeemedurgentlynecessarybyaregistered athletictrainer,coach,ormedicalpractitioner. Iunderstandthatthissportspreparticipationphysicalexaminationisnotdesignednorintendedtosubstituteforanyrecommendedregularcomprehensivehealth assessment. Iherebyauthorizereleaseoftheseexaminationresultstomychild'sschool. Signed:

Parent/Guardian

Date:

ORS336.479,Section1(3)"Aschooldistrictshallrequirestudentswhocontinuetoparticipateinextracurricularsportsingrades7through12tohaveaphysicalexaminationonceeverytwo years."Section1(5)Anyphysicalexaminationrequiredbythissectionshallbeconductedbya(a)physicianpossessinganunrestrictedlicensetopracticemedicine;(b)licensednaturopathic physician;(c)licensedphysicianassistant;(d)certifiednursepractitioner;ora(e)licensedchiropracticphysicianwhohasclinicaltrainingandexperienceindetectingcardiopulmonarydiseases anddefects.

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SchoolSportsPreParticipationExaminationPart2:MedicalProviderCompletes
NAME:
Weight: L20/ %BodyFat(optional): Corrected:Y N Pulse: Unequal BIRTHDATE:

RevisedMay2010
/ /

Height:

BP:____/____(____/____,____/____) Rhythm:Regular_____Irregular_____

Vision:R20/

Pupils:Equal

MEDICAL Appearance Eyes/Ears/Nose/Throat LymphNodes Heart:Pericardialactivity 1 &2 heartsounds Murmurs Pulses:brachial/femoral Lungs Abdomen Skin MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand Hip/thigh Knee Leg/ankle Foot
*Stationbasedexaminationonly
st nd

NORMAL

ABNORMALFINDINGS

INITIALS*

CLEARANCE
Cleared Clearedaftercompletingevaluation/rehabilitationfor: Notclearedfor: Date:

Reason:

Recommendations:

NameofMedicalProvider:

(printortype)

Address:

Phone:( )

SignatureofMedicalProvider:

ORS336.479,Section1(3)"Aschooldistrictshallrequirestudentswhocontinuetoparticipateinextracurricularsportsingrades7through12tohaveaphysicalexaminationonceeverytwo years."Section1(5)Anyphysicalexaminationrequiredbythissectionshallbeconductedbya(a)physicianpossessinganunrestrictedlicensetopracticemedicine;(b)licensednaturopathic physician;(c)licensedphysicianassistant;(d)certifiednursepractitioner;ora(e)licensedchiropracticphysicianwhohasclinicaltrainingandexperienceindetectingcardiopulmonarydiseases anddefects.

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SUGGESTEDEXAMPROTOCOLFORTHEPHYSICIAN

RevisedMay2010

MUSCULOSKELETAL
Havepatient: 1.Standfacingexaminer 2.Lookatceiling,floor,overshoulders,touchearstoshoulders 3.Shrugshoulders(againstresistance) 4.Abductshoulders90degrees,holdagainstresistance 5.Externallyrotatearmsfully 6.Flexandextendelbows 7.Armsatsides,elbows90degreesflexed,pronate/supinatewrists 8.Spreadfingers,makefist 9.Contractquadriceps,relaxquadriceps 10.Duckwalk4stepsawayfromexaminer 11.Standwithbacktoexaminer 12.Kneesstraight,touchtoes 13.Riseuponheels,thentoes Tocheckfor: ACjoints,generalhabitus Cervicalspinemotion Trapeziusstrength Deltoidstrength Shouldermotion Elbowmotion Elbowandwristmotion Handandfingermotion,deformities Symmetryandknee/ankleeffusion Hip,kneeandanklemotion Shouldersymmetry,scoliosis Scoliosis,hipmotion,hamstrings Calfsymmetry,legstrength

MURMUREVALUATIONAuscultationshouldbeperformedsitting,supineandsquattinginaquietroomusingthediaphragmandbellofa stethoscope.
Auscultationfindingof: 1.S1heardeasily;notholosystolic,soft,lowpitched 2.NormalS2 3.Noejectionormidsystolicclick 4.Continuousdiastolicmurmurabsent 5.Noearlydiastolicmurmur 6.Normalfemoralpulses (Equivalenttobrachialpulsesinstrengthandarrival) Rulesout: VSDandmitralregurgitation Tetralogy,ASDandpulmonaryhypertension Aorticstenosisandpulmonarystenosis Patentductusarteriosus Aorticinsufficiency Coarctation

MARFANSSCREENScreenallmenover60andallwomenover510inheightwithechocardiogramandslitlampexamwhenanytwoofthe followingarefound:
1.FamilyhistoryofMarfanssyndrome(thisfindingaloneshouldpromptfurtherinvestigation) 2.Cardiacmurmurormidsystolicclick 3.Kyphoscoliosis 4.Anteriorthoracicdeformity 5.Armspangreaterthanheight 6.Uppertolowerbodyratiomorethan1standarddeviationbelowmean 7.Myopia 8.Ectopiclens

CONCUSSIONWhencananathletereturntoplayafteraconcussion?
Aftersufferingaconcussion,noathleteshouldreturntoplayorpracticeonthesameday.Previously,athleteswereallowedtoreturntoplayiftheirsymptoms resolvedwithin15minutesoftheinjury.Studieshaveshownthattheyoungbraindoesnotrecoverthatquickly,thustheOregonLegislaturehasestablisheda rulethatnoplayershallreturntoplayfollowingaconcussiononthatsamedayandtheathletemustbeclearedbyanappropriatehealthcareprofessional beforetheyareallowedtoreturntoplayorpractice. Onceanathleteisclearedtoreturntoplaytheyshouldproceedwithactivityinastepwisefashiontoallowtheirbraintoreadjusttoexertion.Theathletemay completeanewstepeachday.Thereturntoplayscheduleshouldproceedasbelowfollowingmedicalclearance: Step1:Lightexercise,includingwalkingorridinganexercisebike.Noweightlifting. Step2:Runninginthegymoronthefield.Nohelmetorotherequipment. Step3:Noncontacttrainingdrillsinfullequipment.Weighttrainingcanbegin.Step4:Fullcontactpracticeortraining. Step5:Gameplay. Ifsymptomsoccuratanystep,theathleteshouldceaseactivityandbereevaluatedbyahealthcareprovider. 5810210041FormandProtocolforSportsPhysicalExaminations TheStateBoardofEducationadoptsbyreferencetheformentitled"SchoolSportsPreParticipationExaminationMay2010"thatmustbeusedtodocumentthe physicalexaminationandsetsouttheprotocolforconductingthephysicalexamination.MedicalprovidersconductingphysicalsonorafterJune30,2010mustuse theformdatedMay2010. NOTE:TheformcanbefoundontheOregonSchoolActivitiesAssociation(OSAA)Websitewww.osaa.org. Stat.Auth:ORS326051 Stats.Implemented:ORS336.479 Hist.:ODE242002,f.&cert.ef.111502;ODE292004(Temp),f.&cert.ef.91504thru22505;ODE42005,f.&cert.ef.21405 OregonSchoolActivitiesAssociation FormsPhysicalExamination2010Revised:05/10

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