Pre-participation Physical Evaluation:
THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM
Date of Exam: ___________ Name: ________________________________________
Date of birth: ___________ Sex: ___________ Age: ___________
School: ___________________________________ Class / Year: __________________
Sport(s): _____________________________________________________________
1. Type of disability:
2. Date of disability:
3. Classification (if available):
4. Cause of disability (birth, disease, accident/trauma, other):
5. List the sports you are interested in playing
Yes
6. Do you regularly use a brace, assistive device, or prosthetic?
7. Do you use any special brace or assistive device for sports?
8. Do you have any rashes, pressure sores, or any other skin problems?
9. Do you have a hearing loss? Do you use a hearing aid?
10. Do you have a visual impairment?
11. Do you use any special devices for bowel or bladder function?
12. Do you have burning or discomfort when urinating?
13. Have you had autonomic dysreflexia?
14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related
(hypothermia) illness?
15. Do you have muscle spasticity?
16. Do you have frequent seizures that cannot be controlled by medication?
Explain “yes” answers here:
19
No