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PRE-PARTICIPATION PHYSICAL EVALUATION FORM (PPE) The IHSAA Pre-participation Physical Evaluation (PPE) is the first and most impo1tant step in providing for the well-being ofIndiana's high school athletes. The form is designed to identify risk factors prior to athletic participation by way ofa thorough medical history and physical examination. The IHSAA, under the guidance ofthe Indiana State Medical Association's Com­ mittee on Sports Medicine, requires that the PPE Fo1m be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assis­ tant (PA). In order to assure that these rigorous standards are met, both organizations endorse the following requirements for completion of the PPE Form: I. The most current version of the IHSAA PPE Form must be used and may not be altered or modified in any way. (available for download at www.ihsaa.org<http://wwwJhsaa.org/>) 2. The PPE Form must be signed by a physician (MD or DO) holding an unlimited license to practice medicine, a nurse practitioner (NP) or a physician assistant (PA) only after the m~dical histo1y is reviewed, the examination performed, and th~ PP~.Form completed in ' , :· ... its entirety. No pre-signed or pre-stamped f01ms will be accepted. · ' 3. SIGNATURES □ The signature must be hand-written. No signature stamps will be acceptec;l. □ The signature and license number must be affixed on page two (2). □ The parent signatures must be affixed to the fonn on pages one (1) and four (4). □ The student-athlete signature must be affixed to pages one (1) and four (4). Your cooperation will help ensure the best medical screening for Indiana's high school athletes. Accept and abide by the decisions ofthe contest officials. Be a good host to opponents and treat them as guests. Cooperate with the coach, players, and cheerleaders in trying to promote sportsmanship. Do unto others as you would have them do unto you. Encourage players to play hard and fair. Follow the rules ofthe contest at all times. Good sportsmanship is the "Golden Rule" in action. Hold assembles before contests to encourage students to display proper behavior. Intervene when inappropriate language or behavior is observed. Judgement calls on the part ofthe officials are not reason for inappropriate behavior. Know, understand, and appreciate the rules ofthe contest. Lose without excuses, win without boasting. Model language and behavior that is non-biased and is inclusive of individuals regardless ofethnicity, race, religion, sex, or disability. Never criticize players or coaches for the loss ofa game. Opposing coaches, participants, cheerleaders, and fans must be respected at all times. Provide opportunities for.informing studen, and adult sp~ctators ofthe.ir responsibility to uphold the standards ofsportsmanship. Questioning an official's call or making negative comments about an official is unacceptable behavior. Recogni2;e and show appreciation for an outstanding play regardless ofthe team the player is on. Shake hands with opponents prior to the contest and wish them good luck. Teach sportsmanship and demand that your players be good sports. Use cheerleaders, pep groups, and other student leaders to help develop a sportsmanship program. Victory celebrations and unscheduled game rallies should not be permitted at events sponsored by your school. Work cooperatively with officials and other contest personnel for an efficient contest. eXercise self-control and be a good example for players and spectators. Yelling, booing, or heckling an official's decision are unacceptable. Zero in on sportsmanship - it's priority#1. Remember, in athletics, as in life, CHARACTER COUNTS! ~ PREPARTICIPATION PHYSICAL EVALUATION HISTORY FORM (Nnte: Tl,/s form is In befilled nut by the patient andparent prior In e.<on1/11at/n11. TIie c.rnmlner should keep a cnpy ofthisform in the chart) Date of Exam --------------------------------------------- Name Date of blrlh Sex __ Age Grade _____ School __________ Sport(s) Medicines and Allergies: Please list all of U1e prescriptlon and over-the-counter medicines and supplements (herbal and nutritional) lhat you arecurrently taking Do you have any allergies? D Yes D No If yes. please Identify specific allergy below. D Medicines D Pollens D Food D Stinging Insects Explain "Yes" answers below. Circle questions you don't know the answers to. GENERALp~~TIONS . Ye,s., fdEDICAL QU~STfDN$'.. .. .. Yes No ' ~ ''.. 1. Has adoct01 ever denied 0< restricted your partlclpalion In sports f0< 26.' Do yau cough, wheeze, 0< have difriculty breathing during or any reason? after exercise? 2. Do you have any ongoing medical conditions? II so. please Identify 27. Have you ever used an Inhaler « taken asthma medicine? below: D Asthma D Anemia D Diabetes D tnreclioos 28. IS lhere anyone in your fan1lly who has aslllma7 Other: 29, Were you born wilhout or a1e you missing a kidney, an eye, atesticle 3. Have you ever spent Ille night In Ille hospital? (males), your spleen. 01 any other organ? 4. Have you ever had surgery? 30. Do you have groin pain or apainful bulge 01 hernia In Ille groin area? HEART HEALTH QUESTIONS ABOUT YOU Yes • llo , 3t . Have you had Infectious mononucleosis (mono) wil11i11 the last monlh? 5. Haveyou ever passeo 0111 or nearly passed oul DURING 0< 32. Do you have any rashes. pressure sores, 010U1er skin problems? AFTER exercise? 33. Have you had a herpes or MRSA skin lnfeclion? 6. Have you ever had discomfort,pain. lightness, 0< p,essure in your 34. Have you ever had a head injury or concussion? chest during exercise? 35. Have you ever had ahit 0< blow to1he head that caused confusion, 7. Does your heart ever race 01 skip beats [Irregular beats} during exercise? prolonged headache, or memory problems? 8. Has adocl01 ever told you that you have any heart problems? If so, 36. Do yau have ahistocy or seizure disorder? check all I/lat apply: D High blood pressure D AI1eart murmur 37. Do you have headaches with exercise? D High cholesterol D AheM Infection 38. Have you ever llad numbness, tingling,or weakness In your arms 01 D Kawasaki disease Other: legs after.beinghit or falling? 0. Has adoct01 ever ordered a test for your heart? (For exnmple, ECG/EKG, 39. Have you ever been unable lo move your arms 01 legs atter being hit echocardiogram} or fafllng? 1O. Do you got lighlheAded or feel more shon or breath u,an expected 40. Have you ever becomP. ill while exercising in theheal? during exercise? 41. Do you gel frequent muscle cramps when exercising? t I. Have you ever had an unexplained selrure? 42. Do you or someone In your family have slci<te cell Vail 01 disease? t2. Do you gel motC tired or shor1 of breath r11ore quickly than your friends 43. Have you had any proo1ems Ylith YoUr eyes or vision? durtng exercise? 44. Have you had a.,y eye InIurles? HEARr KLUTH 'QUESTIONS ABOU)' '{OOR FAMILY Yes No 45. Do yau wear glasses 0< contact lenses? 13. Has any family member or relatlvo died ot heart problonis 01 had an 46. Do you wear ptoleclive eycwear, SUCh as goggles 01 aface shield? unexpected or unexplalneo sudden death bef01eage 50 Oncluding drowning, unexplained car accklent, 01 sudden Infant death syndrome}? 47. Do you w01ry abOUl your weight? t4. Docs anyone in your family nave hypertrophlc cardiomyopathy, Marfan 48. Ale you trying to 0< has anyone recommended that you gain or syndrome. anhylhmogenlc right ventricular ca rdlomyopathy,long OT lose weight? syndrome. Shoo1 DT syndrome. Brugada syndr0111e. 01 catecholaminergic 49. Ale you on a special diet or do yau avoid certain types or foods? polymorphic ventricular tachycardia? SO. Haveyou ever had an ealing !isord.lr? ts. Does anyone In your family have aheart problem, pacemaker, or implanted defiMllator? 51. Do you have any concerns that you wouldlike to discuss with adoclor? 16. Has anyone rn your family had unexplained fainting, unexplained fEMA!-£..SO,!ILY seizures, or near drowning? 52. Have you ever had a menstrual period? BONE AND JOINT, QUESTI~NS . Yes ·No , 53. How old were you when you had yoor first menstrual period? 17. Have you ever had an Injury to a bone, muscle, ligament. or tendon 54. How many periods have you had In lhe last 12 monlhs? lhnt caused you tomiss apractice 01 agame? Expla:n "yes" answers here 18. Have you ever had any broken or fractured hones or dislOcated loints? 19. Have you ever had an Injury that required x-rays. MRI, CT sc.in, injections, therapy,a brace. a casl, or crutches? 20. Have you ever had astress fracture? 21. Have you ever been told that you have or have you had an x-ray 10< neck instability or allanloaxial inslabilily? (Down syndrome or dwarfism} 22. Do you regularly use abrace, orthotlcs. or olller assrstive device? 23. Do you 11ave a bone. muscle, or Joint Injury that boU1ets you? 24. Do any or your joints become painful. swollen. reel w,11m. or look red? 25. Do you have any history or juvenile arthritis or connective tiSSlJe disease? I hereby statethat, to t~!J best of my kno~'.ledge, ll!Y answers to theabove questions ar~col11~ete_~il,d corre~t. Signature of athlete • .·• · · . ,· ·,.,. ,· Signature of parent/guardian_i__..,,,_t....,....._...,',.,•-=-=c--- - - - .,--- Date _____ _ ©2010 American Academy ofFamily Pliy.w'da11s, America11 Academy ofPediatrics, American College ofSports Mtdicin~, American SocietyfnrSports Medicine, American Orthopaedic Sodttyfor Sports Medicine, andAml!ricun Osteopathic Academy ofSports ltftdicittt. Perminiott i.t grantetl to reprintfor noncommerchll, ~ducationa/ purpo.tt.t with ack11owledgemen1. This form /ras been modifieil by the lndiuno High Sc/roof Athletic A.,sociarion, /11 c. (If/SAA). (1 of 4) ~ PREPART ICIPAT ION PHYSICAL EVALUATION PHYSICAL EXAMINATION FORM (The physical exa111inatio11 must beperformed on 01· after April I by aphysicia11 holtli11g a11 u11/i111iteJ /ice11se to pmctice 111cdici11c, a 11ursc practitio11cr or a physicia11 assista11110 be validfor thcfollowi11g schoolyear.) THSAA By-Law 3-10 Name Data of birth _________ PHYSICIAN REMINDERS 1.

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