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2020-21 NCISAA Pre-Participation Physical Form

Pleae click here to download the Physician's Form to print and take to your child's physician. Physical examination must be completed by Licensed Physician, Nurse Practitioner, or Physician Assistant.

After the student-athlete's physical, return here to complete the online portion and upload the aforementioned, completed form at the bottom where indicated.

This is a screening examination for participation in sports. This DOES NOT substitute for a comprehensive examination with your child’s regular physician where important preventive health information can be covered. 

Student-Athlete’s Directions: Please review all questions with your parent or legal custodian and answer them to the best of your knowledge. 

Parent/Legal Custodian Directions: Please make sure that all questions are answered to the best of your knowledge. If you do not understand or are unsure about the answer to a question, please ask your doctor. Not disclosing accurate information may put your child at risk during sports activity.  

Please select the sport the student-athlete plans on playing each season.
If he/she does not wish to play a sport in a certain season, leave it blank.
If he/she decides at a later date to play an additional sport, there is no need to complete a second form.

Fall Sports
Answer Required
Winter Sports
Answer Required
Please check the box if you also wish to participate in the Shooting Team during the winter
Answer Required
Spring Sports
Answer Required
Gender*
Answer Required
Explain “Yes” or “Unsure” answers in the space provided below.*
Answer Required
Yes
No
Unsure
1. Does the athlete have any chronic medical illnesses [diabetes, asthma (exercise asthma), kidney problems, migraine, etc.)?
2. Is the student-athlete presently taking any medications or pills?
3. Does the student-athlete have any allergies (medicine, bees or other stinging insect, latex)?
4. Does the student-athlete have the sickle cell trait?
5. Has the student-athlete ever had a head injury, been knocked out, or had a concussion?
6. Has the student-athlete ever had a heat related injury (heat stroke) or severe muscle cramps with activities?
7. Has the student-athlete ever passed out or nearly passed out DURING exercise, emotion, or startle?
8. Has the student-athlete ever fainted or passed out AFTER exercise?
9. Has the student-athlete had extreme fatigue (been really tired) with exercise (different from other children)?
10. Has the student-athlete ever had trouble breathing during exercise, or a cough with exercise?
11. Has the student-athlete ever been diagnosed with exercise-induced asthma?
12. Has a doctor ever told the student athlete that they have high blood pressure?
13. Has a doctor ever told the student-athlete that they have a heart infection?
14. Has the doctor ever ordered an EKG or other test for the student-athlete’s heart, or has the athlete ever been told they have a heart murmur?
15. Has the student-athlete ever had discomfort, pain, or pressure in their chest during or after exercise or complained of their heart “racing” or “skipping beats”?
16. Has the student-athlete ever had a seizure or been diagnosed with an unexplained seizure problem?
17. Has the student-athlete ever had a stinger, burner, or pinched nerve?
18. Has the student-athlete ever had any problems with their eyes or vision?
19. Has the student-athlete ever had an eating disorder, or are there concerns about his/her eating habits or weight?
20. Has the student-athlete ever been hospitalized or had surgery?
21. Has the student-athlete had a medical problem or injury since their last evaluation?
22. Indicate each body part that the student-athlete has ever sprained/strained, dislocated, fractured, broken had repeated swelling in or had any other type of injury to any bones or joints?*
Answer Required
Yes
No
Head
Shoulder
Thigh
Neck
Elbow
Knee
Forearm
Shin/Calf
Back
Wrist
Ankle
Hand
Chest
Foot
Hip
Other (if yes, indicate below in the space below)
23. Indicate if any statement applies to the student-athlete, elaborate in the space provided below.*
Answer Required
Yes
No
Unsure
a. Has the student-athlete had little interest or pleasure in doing things?
b. Has the student-athlete been feeling down, depressed, or hopeless for more than 2 weeks in a row?
c. Has the student-athlete been feeling bad about himself/herself that they are a failure, or let their family down?
Has the student-athlete had thoughts that he/she would be better off dead or hurting themselves or others?
FAMILY HISTORY*
Answer Required
Yes
No
Answer
24. Has any family member had a sudden, unexpected, death before age 50 (including from sudden infant death syndrome [SIDS], car accident, or drowning)?
25. Has any family member had unexplained heart attacks, fainting, or seizures?
26. Does the athlete have a father, mother, or brother with sickle cell disease?

By checking the boxes below, I agree that I have reviewed and answered each question above. Every question is answered completely and is correct to the best of my knowledge. Furthermore, as parent or legal custodian, I give consent for this examination and give permission for my child to participate in sports. 

Answer Required
Answer Required
Upload your completed Physical Form here*
*Physical examination must be completed by Licensed Physician, Nurse Practitioner, or Physician Assistant
Answer Required
or drag it here.
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