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Fill Out Your Illinois Pre Participation Physical Form

The Illinois Pre Participation Physical form is a document designed to assess a student athlete's physical readiness to engage in sports activities. This form, which must be completed by an athlete or their parent prior to a medical examination, collects important medical history and current health information. Ensuring that the form is accurately filled out is crucial for the health and safety of the athlete; click the button below to begin the process.

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Article Structure

The Illinois Pre Participation Physical form serves as a vital tool in safeguarding the health of student-athletes before they engage in sports activities. This comprehensive document addresses various aspects of an athlete's medical history, ensuring that both the parents and the athletes alike are actively involved in the process. At the outset, the form requires essential personal information, including the athlete's name, birthdate, and contact details, which help in identifying individuals accurately. It emphasizes the importance of disclosing any current medications, allergies, and past medical incidents, forming a critical foundation for the medical assessment. Furthermore, the form delves into specific areas of health, such as heart conditions, bone and joint issues, and other medical concerns that might affect participation in sports. Sections dedicated to heart health, for instance, inquire about any prior heart issues or related family history, ensuring that potential risks are identified early on. The examination culminates with a physical assessment, where doctors evaluate various aspects of the athlete's condition, including vital signs and musculoskeletal health. Finally, provisions for consent regarding random testing for performance-enhancing substances are included, reflecting the ongoing commitment to fair play and athlete integrity. Thus, the Illinois Pre Participation Physical form is not merely a bureaucratic requirement; it is a crucial safeguard, aimed at ensuring that young athletes are physically fit and healthy enough for the demands of their sports.

Illinois Pre Participation Physical Example

Pre-participation Examination

To be completed by athlete or parent prior to examination.

Name

School Year

Last

First

Middle

Address

City/State

Phone No.

Birthdate

Age

Class

Student ID No.

Pare t’s Na e

Phone No.

Address

City/State

HISTORY FORM

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	 Stinging Insects

E plain Yes answe s elow. Ci	le uestions ou don’t know the answe s to.


	GENERAL QUESTIONS				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				Yes	No
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?
8.		Has a doctor ever told you that you have any heart problems? If
		so, check all that apply:  High blood pressure  A heart murmur
		 High cholesterol  A heart infection  Kawasaki disease
		Other: ___		______

9.		Has a doctor ever ordered a test for your heart? (For example,
		ECG/EKG, echocardiogram)
10.		Do you get lightheaded or feel more short of breath than
		expected during exercise?
11.		Have you ever had an unexplained seizure?
12.		Do you get more tired or short of breath more quickly than your
		friends during exercise?
	HEART HEALTH QUESTIONS ABOUT YOUR FAMILY				Yes	No
13.		Has any family member or relative died of heart problems or had
		an unexpected or unexplained sudden death before age 50
		(including drowning, unexplained car accident, or sudden infant
		death syndrome)?
14.		Does anyone in your family have hypertrophic cardiomyopathy,
		Marfan syndrome, arrhythmogenic right ventricular
		cardiomyopathy, long QT syndrome, short QT syndrome, Brugada
		syndrome, or catecholaminergic polymorphic ventricular
		tachycardia?
15.		Does anyone in your family have a heart problem, pacemaker, or
		implanted defibrillator?
16.		Has anyone in your family had unexplained fainting, unexplained
		seizures, or near drowning?
	BONE AND JOINT QUESTIONS				Yes	No
17.		Have you ever had an injury to a bone, muscle, ligament, or
		tendon that caused you to miss a practice or a game?
18.		Have you ever had any broken or fractured bones or dislocated
		joints?
19.		Have you ever had an injury that required x-rays, MRI, CT scan,
		injections, therapy, a brace, a cast, or crutches?
20.		Have you ever had a stress fracture?
21.		Have you ever been told that you have or have you had an x-ray
		for neck instability or atlantoaxial instability? (Down syndrome or
		dwarfism)
22.		Do you regularly use a brace, orthotics, or other assistive device?
23.		Do you have a bone, muscle, or joint injury that bothers you?
24.		Do any of your joints become painful, swollen, feel warm, or look
		red?
25.		Do you have any history of juvenile arthritis or connective tissue
		disease?

MEDICAL QUESTIONS

Yes

26.Do you cough, wheeze, or have difficulty breathing during or after exercise?

27.	Have you ever used an inhaler or taken asthma medicine?
28.	Is there anyone in your family who has asthma?
29.	Were you born without or are you missing a kidney, an eye, a
	testicle (males), your spleen, or any other organ?
30.	Do you have groin pain or a painful bulge or hernia in the groin
	area?
31.	Have you had infectious mononucleosis (mono) within the last
	month?
32.	Do you have any rashes, pressure sores, or other skin problems?
33.	Have you had a herpes or MRSA skin infection?
34.	Have you ever had a head injury or concussion?
35.	Have you ever had a hit or blow to the head that caused
	confusion, prolonged headache, or memory problems?
36.	Do you have a history of seizure disorder?
37.	Do you have headaches with exercise?
38.	Have you ever had numbness, tingling, or weakness in your arms
	or legs after being hit or falling?
39.	Have you ever been unable to move your arms or legs after being
	hit or falling?
40.	Have you ever become ill while exercising in the heat?
41.	Do you get frequent muscle cramps when exercising?
42.	Do you or someone in your family have sickle cell trait or disease?
43.	Have you had any problems with your eyes or vision?
44.	Have you had any eye injuries?
45.	Do you wear glasses or contact lenses?
46.	Do you wear protective eyewear, such as goggles or a face shield?
47.	Do you worry about your weight?
48.	Are you trying to or has anyone recommended that you gain or
	lose weight?
49.	Are you on a special diet or do you avoid certain types of foods?
50.	Have you ever had an eating disorder?
51.	Have you or any family member or relative been diagnosed with
	cancer?
52.	Do you have any concerns that you would like to discuss with a
	doctor?
FEMALES ONLY		Yes	No
53.	Have you ever had a menstrual period?

54.How old were you when you had your first menstrual period?

55.How many periods have you had in the last 12 months?

Explain es answe s he e

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of athlete

Signature of parent/guardian

Date

©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical 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 acknowledgment. HE0503

Pre-participation Examination

PHYSICAL EXAMINATION FORM

EXAMINATION

Height

Weight

 Male

 Female

(

)

Pulse

Vision R 20/

L 20/

Corrected

 Y  N

MEDICAL

NORMAL

ABNORMAL FINDINGS

Appearance

• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum,

arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

Pupils equal

Hearing

Lymph nodes

Heart a

Murmurs (auscultation standing, supine, +/- Valsalva)

Location of point of maximal impulse (PMI)

Pulses

Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only)b

Skin

HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/Ankle

Foot/toes

Functional

Duck-walk, single leg hop

aConsider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam.

bConsider GU exam if in private setting. Having third party present is recommended.

cConsider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.

O the

asis of the e a i

atio

o this da

, I appro e this

hild’s parti ipatio i

i ters holasti

sports for o

e year.

Yes

Limited

Examination Date

Additional Comments:

Ph	si ia	’s Sig ature
Ph	si ia	’s Assista t Sig ature*
Ad a ed Nurse Pra titio er’s Sig ature*
*effective January 2003, the IHSA Board of Dire tors appro ed a re o			e datio , o siste t ith the Illi ois S hool Code, that allo s Ph si ia ’s Assista ts or
Advanced Nurse Practitioners to sign off on physicals.

IHSA Steroid Testing Policy Consent to Random Testing

(This section for high school students only)

2011-2012 school term

As a prerequisite to participation in IHSA athletic activities, we agree that I/our student will not use performance-enhancing substances as defined in the IHSA Performance-Enhancing Substance Testing Program Protocol. We have reviewed the policy and understand that I/our student may be asked to submit to testing for the presence of performance-enhancing substances in my/his/her body either during IHSA state series events or during the school

day, and I/our student do/does hereby agree to submit to such testing and analysis by a certified laboratory. We further understand and agree that the results of the performance-enhancing substance testing may be provided to certain individuals in my/our student’s high school as specified in the IHSA

Performance-Enhancing Substance Testing Program Protocol which is available on the IHSA website at www.IHSA.org. We understand and agree that the results of the performance-enhancing substance testing will be held confidential to the extent required by law. We understand that failure to provide accurate and truthful information could subject me/our student to penalties as determined by IHSA.

A complete list of the current IHSA Banned Substance Classes can be accessed at

http://www.ihsa.org/initiatives/sportsMedicine/files/IHSA_banned_substance_classes.pdf


	Signature of student-athlete		Date		Signature of parent-guardian		Date

Get Illinois Pre Participation Physical PDF Form

Form Characteristics

Fact Name	Details
Purpose of the Form	The Illinois Pre Participation Physical form is designed to assess an athlete's health status before they participate in school sports.
Required Information	The form requires personal details such as the athlete's name, address, birthdate, and medical history, including allergies and past injuries.
Medical Examination	A physical examination by a qualified medical professional is needed to evaluate the athlete's general health and fitness for sports participation.
Usage Frequency	This form must be completed and submitted annually for each athlete to ensure current health status is taken into account.
Governing Laws	The form complies with the Illinois School Code (105 ILCS 5) and regulations set by the Illinois High School Association (IHSA).

Guidelines on Utilizing Illinois Pre Participation Physical

Filling out the Illinois Pre Participation Physical form is an essential step in ensuring that all relevant information about the athlete's health is collected for review. This step-by-step guide will assist you in completing the form accurately.

Begin with the athlete's personal information. Fill in the Name, Address, City/State, Phone No., Birthdate, Age, Class, and Student ID No..
Provide the parent's name and phone number, as well as their address and city/state.
Complete the Medications and Allergies section. List any current medications, both prescription and over-the-counter. Indicate if the athlete has any allergies by checking Yes or No and specifying the allergies if applicable.
Answer the General Questions. For each question, mark Yes or No. Include any additional details in the space provided.
Proceed to the Heart Health Questions About You and mark Yes or No for each question, adding explanations for any affirmative answers.
Continue with the Heart Health Questions About Your Family. Again, indicate Yes or No and provide necessary context where required.
Next, fill out the Bone and Joint Questions, marking Yes or No as applicable.
Complete the Medical Questions section by responding to each inquiry.
If applicable, respond to the Females Only section, indicating Yes or No as needed.
Sign the form to affirm the completeness and accuracy of the information provided. Both athlete and parent/guardian should sign and date the form.
Complete the Physical Examination Form by providing details on height, weight, blood pressure, pulse, and vision.
Finally, the physician or their appointed representative will complete the Medical and Musculoskeletal Evaluation, including their signature.

These steps will guide you through the form. It’s crucial to be thorough and accurate, as this information contributes significantly to ensuring safety in sports participation. Following the completion, the form can be submitted as required by the school or athletic organization for review.

What You Should Know About This Form

What is the Illinois Pre Participation Physical form?

The Illinois Pre Participation Physical form is a required document for student-athletes before they participate in sports. It collects important health information about the athlete, including medical history, current health issues, and family health history. This form helps ensure that the athlete is fit to participate in physical activities safely. Parents or guardians may need to assist in completing this form, which must be submitted ahead of any sports season.

Who needs to fill out the form?

All student-athletes participating in interscholastic sports in Illinois must complete the Pre Participation Physical form. This includes students from middle school and high school levels. It is essential for first-time participants as well as returning athletes, as the health information may change each year.

What information is required on the form?

The form requires various details, including the athlete's name, birthdate, and ID number. It includes a thorough medical history questionnaire, which covers past injuries, allergies, surgeries, and relevant family medical history. Specific sections address heart health, bone and joint issues, and other medical concerns. This comprehensive approach aims to identify any potential risks associated with participating in sports.

How is the form submitted?

What happens if the athlete has a medical condition?

If an athlete has a medical condition, it is essential to disclose this information on the form. Parents or guardians should provide accurate details regarding the condition and any necessary accommodations. This transparency allows school staff to assess the athlete’s readiness to participate in sports safely. In some cases, additional medical evaluations may be required.

Is parental signature required?

Common mistakes

Completing the Illinois Pre Participation Physical form correctly is crucial for ensuring the safety and well-being of student-athletes. However, several common mistakes can lead to complications during the evaluation process. One frequent error is leaving out important medical history information. Parents and athletes often overlook past surgeries or ongoing medical conditions, which are essential for the physician to know. Omitting such details can affect the assessment and ultimately the athlete’s ability to participate safely.

Another common mistake involves failing to list all current medications and allergies. Some individuals may forget to include over-the-counter medicines or supplements, thinking they are not relevant. This can create significant risks, especially if the physician is unaware of potential interactions or allergic reactions that may occur during physical activity.

Many people also tend to skip questions related to heart health. Questions about fainting during exercise or family history of heart problems are particularly important. Ignoring these questions can prevent healthcare providers from identifying underlying issues that could pose serious risks during sports participation.

In addition, individuals sometimes answer “no” to questions when they may not be entirely sure of their condition. For example, questions about previous concussions or injuries might warrant further explanation or clarification. Providing vague answers can lead to misinterpretation of an athlete's health status, leading to inadequate precautions being taken.

Another area of concern is the lack of communication regarding physical disabilities or past injuries. Individuals may choose not to disclose mild or past injuries, assuming they are no longer relevant. However, such information can aid the medical team in making informed decisions regarding participation levels and necessary precautions.

Lastly, failing to obtain the required signatures from both the athlete and a parent or guardian can result in the form being rejected. This simple oversight can delay the approval process, potentially hindering a student's timely participation in sports. Ensuring all sections of the form are thoroughly reviewed and completed can help avoid these pitfalls.

Documents used along the form

The Illinois Pre Participation Physical form is a crucial document for student-athletes, ensuring their health and safety before engaging in sports. Besides this form, several other documents are commonly used in conjunction to provide a comprehensive view of the athlete's health and eligibility. Here’s a brief overview of those documents.

Concussion Management Plan: Outlines procedures for handling suspected concussions, including return-to-play protocols.
Emergency Contact Form: Lists contacts in case of an emergency during practice or events, ensuring timely communication and assistance.
Insurance Verification Form: Confirms that the athlete has appropriate health insurance coverage to handle potential injuries incurred during sports activities.
Drug Testing Consent Form: Specifies consent for drug testing, often required in high school sports to deter the use of performance-enhancing substances.
Sports Physical Examination Record: A detailed account of the athlete’s physical exam results, including health history and a physician's signature for participation approval.
Informed Consent Agreement: Provides information about the risks associated with participation in sports and secures the athlete's agreement to these terms.
Waiver and Release of Liability: A legal document that protects the school or organization from liability in the event of injury or accident during sports activities.
Parent Authorization Form: Authorizes school staff to seek medical treatment for the athlete if they are injured or become ill during practice or games.

Having these forms and documents completed and submitted is essential for a smooth athletic experience. They promote safety, ensure compliance with regulations, and facilitate communication among parents, athletes, and school officials.

Similar forms

The Illinois Pre Participation Physical form is crucial for ensuring the health and safety of student-athletes. It shares similarities with several other important documents that serve the same purpose in different jurisdictions or contexts. Below is a detailed list of eight such documents and how they are akin to the Illinois form.

California Pre-Participation Physical Evaluation form: Like the Illinois form, this document collects a comprehensive medical history, including questions about past injuries, existing medical conditions, and family health history, ensuring thorough evaluation before sports participation.
Texas Sports Physical Form: This form also focuses on a thorough examination and includes medical history questions tailored to identify any potential health risks before engaging in sports. The format encourages both the athlete and the guardian to understand existing health issues.
New York State Pre-Participation Physical Evaluation (PPPE) form: Similar in purpose, this document mandates a full medical history and physical examination, allowing healthcare providers to assess an athlete’s readiness to compete and protect them from potential health concerns.
Florida Athletic Pre-Participation Examination: This document also gathers detailed medical and family history, aiming to uncover any health issues that could jeopardize the athlete's safety during physical activities, mirroring the comprehensive approach of the Illinois form.
Ohio High School Athletic Association Physical Form: The Ohio form requires information regarding past medical conditions and injuries, paralleling the Illinois form in ensuring that potential health threats are identified prior to sports participation.
Michigan High School Athletic Association Health Questionnaire: This document emphasizes a thorough review of medical history similar to the Illinois form, placing a focus on previous injuries, chronic health issues, and family medical history impacting athletic eligibility.
Pennsylvania Pre-Participation Sports Physical: This form encapsulates medical screening similar to the Illinois form, ensuring that athletes disclose their health history and undergo a complete physical examination to ascertain their fitness for participation.
National Federation of State High School Associations (NFHS) Physical Examination form: Like the Illinois form, the NFHS form includes detailed medical history questions, emphasizing the importance of assessing athletes' health and safety prior to participating in high school sports.

Each of these documents aims to protect the athlete by ensuring a safe environment for sports participation, requiring detailed health assessments and histories similar to what is mandated by the Illinois Pre Participation Physical form.

Dos and Don'ts

When filling out the Illinois Pre Participation Physical form, it’s essential to approach the process carefully. Here are some do's and don'ts to guide you through:

Do ensure all personal information is accurate, including the athlete's name and birthdate.
Do provide complete details about any medications, allergies, and ongoing health conditions.
Do discuss any medical history with the athlete to answer questions thoroughly.
Do review the form with a parent or guardian to confirm all answers are agreed upon.
Don’t leave any questions unanswered, even if you're unsure. It's better to circle questions you can't answer than skip them.
Don’t exaggerate or minimize symptoms. Honesty is critical for the athlete's safety.
Don’t forget to sign and date the form, as it’s required for participation.
Don’t hesitate to ask for help or clarification about any section of the form; your health professional's input can be invaluable.

Completing this form accurately and completely ensures that the athlete has a safe and healthy participation in sports.

Misconceptions

Understanding the Illinois Pre Participation Physical form is crucial for ensuring the safety and health of student athletes. However, several misconceptions often arise regarding this important document. Below are some common misunderstandings, addressed for clarity.

The exam is only for high-risk sports. Many believe that the physical exam is only necessary for contact or high-risk sports. In reality, it is required for all sports participants to ensure that every athlete is fit for competition.
Parents can fill out the form without any input from the athlete. Some think that parents can simply complete the form without consulting their child. It's essential that the athlete provides accurate information about their health and experiences, as they are the ones participating in the activity.
Previous health issues don’t need to be disclosed if the athlete feels fine. There’s a misconception that only current health status matters. However, disclosing past injuries or health problems is critical, as they can affect an athlete's ability to participate safely.
A doctor's signature guarantees no health issues. Many people mistakenly believe that obtaining a doctor's signature on the form means the athlete has no potential health concerns. While a doctor's evaluation is essential, it does not eliminate all risks associated with physical activity.

Clear communication and understanding surrounding the Illinois Pre Participation Physical form are vital for the well-being of student athletes. Each athlete should take their health seriously and ensure they provide thorough and honest information.

Key takeaways

The Illinois Pre Participation Physical form is essential for ensuring that students are physically prepared to participate in sports. Here are eight key takeaways to consider when filling out and utilizing this form:

Complete all sections accurately: Provide detailed and truthful information about medical history, allergies, and medicines being taken. Inaccurate details may pose health risks.
Be thorough with the medical history: The form includes questions about past medical conditions, surgeries, and hospital visits. Answering these questions honestly is crucial for the safety of the athlete.
Heart health evaluation is critical: Specific inquiries regarding heart health can help identify any fitness risks related to cardiovascular issues. Be candid about any family history of heart problems.
Attention to bone and joint health: Indicating previous injuries or conditions is important. This information helps healthcare professionals assess recovery needs for athletes.
Consult with a physician: A physician's signature is mandatory to validate the form. Schedule an appointment for a comprehensive physical examination as required.
Date is essential: Ensure the completion date is included. This timestamp indicates the validity of the examination and informs coaches when re-evaluation will be necessary.
Stay informed about substance policies: Familiarize yourself with the IHSA’s steroid testing policy. Understanding the implications can better prepare athletes and their families.
Follow up if complications arise: If any answers on the form indicate potential health issues, further medical evaluation may be required. Don’t hesitate to seek additional guidance from healthcare providers.

Remember, this form is a protective measure aimed at ensuring the safety and well-being of student-athletes. It is imperative to approach the process with diligence and care.

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