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1890 AL HWY 157, Suite 430 Cullman, AL 35058
(256) 567-4300
Review Us
Home
About IMPC
Practice Areas
Internal Medicine
Primary Care
Pediatrics
Other Specialties
Patient Forms
FAQs
Contact
Resources
Dosage Charts
Vaccine ScheduleÂ
Review Us
Sports Physical Questionnaire
Sports Physical Questionnaire
Name
This field is for validation purposes and should be left unchanged.
Parent/Guardian Name
(Required)
First
Last
Student Athlete Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
Sex
(Required)
Select One
Male
Female
Rather Not Say
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
School Name
(Required)
Grade
(Required)
Sport
(Required)
Have you ever fainted, passed out, or had an unexplained seizure suddenly and without warning, especially during exercise or in response to sudden loud noises, such as doorbells, alarm clocks, and ringing telephones?
(Required)
YES
NO
Please Explain
(Required)
Have you ever had exercise-related chest pain or shortness of breath?
(Required)
YES
NO
Please Explain
(Required)
Has anyone in your immediate family (parents, grandparents, siblings) or other, more distant relatives (aunts, uncles, cousins) died of heart problems or had an unexpected sudden death before age 50? This would include unexpected drownings, unexplained auto crashes in which the relative was driving, or SIDS (Sudden Infant Death Syndrome).
(Required)
YES
NO
Please Explain
(Required)
Are you related to anyone with hypertrophic cardiomyopathy/hypertrophic obstructive cardiomyopathy, Marfan syndrome, arrhythmogenic cardiomyopathy, long QT syndrome, short QT syndrome, baroreceptor sensitivity, or catecholaminergic polymorphic ventricular tachycardia or anyone younger than 50 years with a pacemaker or implantable defibrillator?
(Required)
YES
NO
Please Explain
(Required)
Has a doctor ever restricted/denied your participation in sports?
(Required)
YES
NO
Please Explain
(Required)
Have you ever been hospitalized or spent a night in a hospital?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had Surgery?
(Required)
YES
NO
Please Explain
(Required)
Do You Have Any Ongoing Medical Conditions (like Diabetes or Asthma)?
(Required)
YES
NO
Please Explain
(Required)
Are You Presently Taking Any Medications or Pills (Presecription or Over-the-Counter)?
(Required)
YES
NO
Please Explain
(Required)
Do You Have Any Allergies (Medicine, Pollens, Foods, Bees, or Other Stinging Insects)?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Passed Out During or After Exercise?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Been Dizzy During or After Exercise?
(Required)
YES
NO
Please Explain
(Required)
Do You Ever Have Chest Pain or Discomfort in Your Chest During or After Exercise?
(Required)
YES
NO
Please Explain
(Required)
Do You Tire Out More Quickly Than Your Friends During Exercise?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had High Blood Pressure?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Been Told That You Have a Heart Murmur, High Cholesterol, or Heart Infection?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had Racing of Your Heart or Skipped Heartbeats?
(Required)
YES
NO
Please Explain
(Required)
Does Anyone in Your Family Have a Heart Condition?
(Required)
YES
NO
Please Explain
(Required)
Has a Doctor Ever Ordered a Test on Your Heart (EKG, Echocardiogram)?
(Required)
YES
NO
Please Explain
(Required)
Do You Have Any Skin Problems (Itching, Rashes, Staph, MRSA, Acne)?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had a Head Injury or Concussion?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Been Knocked Out or Unconscious?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had a Seizure?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had a Stinger, Burner, Pinched Nerve, or Loss of Feeling or Weakness in Your Arms or Legs?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had Heat or Muscle Cramps?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Been Dizzy or Passed Out in the Heat?
(Required)
YES
NO
Please Explain
(Required)
Do You Have Trouble Breathing or Do You Cough During or After Activity?
(Required)
YES
NO
Please Explain
(Required)
Do You Take Any Medications for Asthma (For Instance, Inhalers)?
(Required)
YES
NO
Please Explain
(Required)
Do You Use Any Special Equipment (Pads, Braces, Neck Rolls, Mouth Guard, Eye Guards, etc.)?
(Required)
YES
NO
Please Explain
(Required)
Do You Wear Glasses or Contacts or Protective Eyewear?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Had Any Other Medical Problems (Infectious Mononucleosis, Infections Diseases, etc.)?
(Required)
YES
NO
Please Explain
(Required)
Have You Had a Medical Problem or Injury Since Your Last Evaluation?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Been Told You Have Sickle Cell Trait?
(Required)
YES
NO
Please Explain
(Required)
Has Anyone in Your Family Had Sickle Cell Disease or Sickle Cell Trait?
(Required)
YES
NO
Please Explain
(Required)
Have You Ever Sprained/Strained, Dislocated, Fractured, Broken or Had Repeated Swelling or Other Injuries of Any Bones or Joints?
(Required)
YES
NO
Where Has This Occurred? (Select All That Apply)
(Required)
Head
Neck
Back
Chest
Shoulder
Elbow
Forearm
Wrist
Hand
Finger
Hip
Thigh
Knee
Shin
Ankle
Foot
Please Explain
(Required)
When Was Your First Menstrual Period?
(Required)
When Was Your Last Menstrual Period?
(Required)
What Was the Longest Time Between Your Periods Last Year?
(Required)
Statement of Understanding
Based upon current guidelines, history and physical exam, and any appropriate testing, there is no obvious reason for exclusion from sports participation. Reasonable medical standards indicate that the child may participate. However, the parent(s) must consider the child's individual risks vs. benefits for participation, and understand that "clearance" is NOT a guarantee against adverse outcomes or future medical problems.
(Required)
I understand the above statement.
Please Confirm Accuracy of Information Provided
(Required)
Yes, I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
