Chesterton High School
CHESTERTON HIGH SCHOOL Preparticipation Physical Evaluation HISTORY FORM Physical MUST be performed AFTER April 1st for 2019/2020 school year (Note: This form is to be fi lled out by the patient and parent prior to examination. The examiner should keep a copy of this form in the chart.) NAME PLEASE WRITE LEGIBLY Grade 2019/2020 X Signature of athlete _____________________ Signature of parent/guardianX _________________________________ Date _____________ ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgement. This form has been modifi ed by the Indiana High School Athletic Association, Inc. (IHSAA). (1 of 4) ■ PREPARTICIPATION PHYSICAL EVALUATION PHYSICAL EXAMINATION FORM (The physical exami11atio11 must be performed011 or r,fterApril 1 by r,physicir111 holdi11g r,11 1111/imited lice11se to practice 111edici11e, r,1111rse practitio11er or r,pl,ysici,111 r,ssistm,tto be validfor tl1efollowi11g scl,oolyear.) - IHSAA By-Law 3-10 NAME PLEASE WRITE LEGIBLY Date of birth 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 youever tried 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 youever taken anabolic steroids or used any other pertormance supplement? • Have youever taken any supplements to help you gain or lose weight or improve yourpertormance? • Do you wear a seat belt, use a helmet, and use condoms? 2.
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