University of Pittsburgh wheelccc | Page 21

Pre-participation Physical Evaluation: HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep a copy of this form in the chart.) Date of Exam: __________________ Name_______________________________________________________________________ Date of birth _____________________________ Sex _____________ Age _______________ Grade ___________________________ School _____________________________________ Sport(s) _____________________________________________________________________ Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking: Do you have any allergies? Yes No If yes, please identify specific allergy below (medicines, pollens, food, sting- ing, insects): GENERAL QUESTIONS Yes No Yes No 1. Has a doctor ever denied or restricted your participation in sports for any reason? 2. Do you have any ongoing medical conditions? If so, please identify below: Asthma Anemia Diabetes Infections Other: _______________________________________________ 3. Have you ever spent the night in the hospital? 4. Have you ever had surgery? HEART HEALTH QUESTIONS ABOUT YOU 5. Have you ever passed out or nearly passed out DURING or AFTER exercise? 6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 7. Does your heart ever race or skip beats (irregular beats) during exercise? 21