1. Clarion Area High School Pre-Participation Exam
Dear Parents,
At Clarion High School, the athletic training staff require that all athletes that intend to participate in athletics
take part in a Pre-Participation Exam. All paper work must be completed by athlete or parent prior to
examination. Examinations will be held at Clarion Area High School on Saturday, August 1st, 2014. Price of
examination will be $10.00. All athletes with last names beginning with letters A through G are to arrive at the
school at 8am, H through N are to arrive at 10:30am, O through U are to arrive at 1:00pm, and V through Z are
to arrive at 3:30pm. Please bring the following packet with all forms that are able to be completed prior,
completed. Due to the large number of athletes that need to be tested, please be patient and courteous of all
other athletes and medical professionals as we are trying to facilitate a quick, and easy examination. The
examinations are to be done station based, utilizing the Certified Athletic Training Devin Skinner, Team Family
Physician Dr. Jan Kenneson, Athletic Director Robert Walters, and Team Orthopedic Surgeon Dr. Robert
Armstrong to perform each aspect of the exams. Athletes will meet in the lobby area to check in and give all
medical history information (all forms in packet besides physical examination information form) to Mr. Walters
and will be assigned a station where they will begin. The physical exam will be done by Dr. Kenneson in the
nurses’ office, orthopedic screening will be done by orthopedic surgeon Dr. Armstrong in the ATR, functional
testing, height, weight, and vision done by Mr. Skinner in the gym, and check out. All forms are to be given to
ATC before departure. Below are the locations of each station that the athlete and parent will go through…
1 = check in
2 = physical
examination/medical
history drop-off
3 = orthopedic screening
4 = height/weight
5 = visionscreening
6 = functional testing
7 = check out
2. Medical Consent/Release for Treatment Form
Athlete Name: __________________________ Sport____________________________
I, _____________________________the Parent or Legal Guardian of __________________________, grant
the team physician, certified athletic training and associated medical staff to medically treat my child who is a
minor. I allow necessary examination and medical treatment by certified athletic trainer, and accompanied
medical staff of Clarion Area High School. Medical treatment includes but is not limited to: initial evaluations,
assessment evaluations, taping and bracing, stretching, cryotherapy, thermotherapy, rehabilitation exercises, and
administering medications. I am also aware that I am giving consent for my son or daughter to be hospitalized if
necessary at an accredited hospital.
You do have the right to refuse to sign this section of this form. If you do not wish to sign the medical consent
section of this form, please print in the signatures line, REFUSE TO CONSENT, and date the refusal.
Parent/Guardian Signature_____________________________________ Date______________
To be completed by parent and/or guardian
3. Student-Athlete Information
Please complete these information sections.
General Information:
First Name: ____________________________.
Middle Initial: ______________.
Last Name: _____________________________.
Sex: Male / Female (circle one)
Date of Birth (mm/dd/yy): ___ /___ /___
Student's SSN: ___________________.
Height (ft., in.):__________________.
Weight (lbs): ___________________.
Student Cell Phone: ( ) – ( ) – ( )
Primary Address:
Address: __________________________________________________________.
City: _______________________________________.
State/Province: ______________.
Zip Code: __________________.
To be completed by parent and/or guardian
4. Health Emergency Contact Information
Please complete these information sections.
First EmergencyContact Name:____________________________________
Relationship toStudentAthlete: ____________________________________
Address: ________________________________________________.
City: ___________________________________.
State/Province: _______________.
Zip Code: _____________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
Second EmergencyContactName: ___________________________________
Relationship toStudent-Athlete: ______________________________________
Address: _________________________________________________.
City: ___________________________________.
State/Province: _____________.
Zip Code: ______________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
Third EmergencyContact Name:___________________________________
Relationship toStudent-Athlete: ______________________________________
Address: _________________________________________________.
City: ___________________________________.
State/Province: _____________.
Zip Code: ______________.
Email Address: ___________________________.
Home Phone: _____________________________.
Cell Phone: ________________________________.
To be completed by parent and/or guardian
5. Clarion Area High School Insurance Verification Form
Please Scan Insurance Card and complete the information by 08/1/14.
Name: ___________________________
Date: ____________________________
Medical (Primary):
Company Name: __________________________________________.
Plan ID: _________________________________.
Group Number: __________________________.
Primary Subscriber: ________________________________.
Subscriber's Date of Birth: ( ) / ( ) / ( ).
Subscriber/policy ID: _________________.
Insurance phone: __________________________.
Status:________________________.
To be completed by parent and/or guardian
Front of Card
Back of Card
6. Health History Questionnaire
Please have athlete answer yes or no to all questions honestly.
General Health Questions:
1. Do you have any allergies? (if yes, please explain)______________________________________________________.
2. Do you take any medications? (if yes, please explain)___________________________________________________.
3. Do you have any on-going medical conditions? Ex. Diabetes, asthma, infections (if so, please explain)
_______________________________________________________________________________________.
4. Has a doctor ever denied or restricted your participation in sports for any reason? (if so, please
explain)_______________________________________________________________________________________.
5. Have you ever had surgery of any kind? (if so, list all procedures and
dates)_________________________________________________________________________________________.
6. Have you ever spent a night in the hospital? (if so, for what and give dates of
visit)_________________________________________________________________________________________
Heart Health Questions about you and your family:
7. Does anyone in your family have the diseases hypertrophic cardiomyopathy, Marfan syndrome, arrhythmgenic right
ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia? (if so, please explain)_____________________________________________
_____________________________________________________________________________________________.
8. Have you ever passed out or nearly passed out DURINGor AFTER exercise? (if so, please
explain)_______________________________________________________________________________________.
9. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? (if so, please
explain)_______________________________________________________________________________________.
10. Have you ever been told you that you have high blood pressure? (if so, please
explain)_______________________________________________________________________________________.
11. Have you ever told that you have a heart murmur? (if so, please explain)____________________________________.
12. Have you ever had a doctor order a heart test for you? Ex. EKG, ECG, echocardiogram (if so, please explain)
_______________________________________________________________________________________.
13. Have you ever had an unexplained seizure? (if so, please explain and give date of last
seizure)________________________________________________________________________________________.
14. Has any family member ever died as a result of a heart condition or had an unexplained sudden death before the age
of 50? (if so, please explain)_______________________________________________________________________.
15. Does anyone in your family have a heart problem, pacemaker,or implanted defibrillator? (if so, please
explain)_______________________________________________________________________________________.
Bone and Joint Questions:
16. Have you ever had a bone or joint injury that caused you to miss a practice or a game? Ex. Ligaments, muscles,
tendons, or bones (if so, please explain) ______________________________________________________________.
7. 17. Have you ever had any broken or fractured bones or dislocated joints? (if so, please
explain)_______________________________________________________________________________________.
18. Have you ever had an injury that required x-rays, MRI, CT scan,injections, therapy, a brace,a cast,or crutches? (if
so, please explain)______________________________________________________________________________.
19. Do you regularly use a brace,orthotics, or other assistive devices? (if so, please
explain)______________________________________________________________________________________.
20. Have you ever been diagnosed with a stress fracture? (if so, please explain and give a
location)______________________________________________________________________________________.
21. Do you have a bone, muscle, or joint injury that bothers you? (if so, please
explain)_______________________________________________________________________________________.
22. Have you ever had an x-ray for neck instability or atlantoaxial instability? (if so, please
explain)_______________________________________________________________________________________.
23. Do you have any history of juvenile arthritis or any connective tissue diseases? (if so, please
explain)_______________________________________________________________________________________.
Medical Questions:
24. Do you have asthma or use a prescribed medical inhaler, or has anyone in your family ever had asthma? (if so, please
explain)_______________________________________________________________________________________.
25. Are you updated on all your immunizations? (if so, please explain)________________________________________.
26. Diabetes? (if so, please explain)____________________________________________________________________.
27. Were you born with a vital organ missing? Ex. Testicle, kidney, eye, spleen (if so, please explain)
_______________________________________________________________________________________.
28. Have you ever been unable to move your arms or legs after a hit or fall? (if so, please
explain)_______________________________________________________________________________________.
29. Have you ever had any numbness or tingling in your arms or legs after a hit or fall? (if so, please
explain)_______________________________________________________________________________________.
30. Have you ever had a groin pain or a hernia? (if so, please explain)_________________________________________.
31. Have you ever had Herpes or MIRSA skin infections? (if so, please
explain)_______________________________________________________________________________________.
32. Have you ever become ill from exercising in the heat? (if so, please
explain)_______________________________________________________________________________________.
33. Do you get frequent muscle cramps when exercising? (if so, please explain)_________________________________.
34. Epilepsy? (if so, please explain)____________________________________________________________________.
35. Seizures/Convulsions? (if so, please explain)__________________________________________________________.
36. Heart Condition? (if so, please explain)______________________________________________________________.
37. Kidney Problems? (if so, please explain)_____________________________________________________________.
38. Migraine: Frequent Headache? (if so, please explain)___________________________________________________.
39. Concussion/Head Injury? (if so, please explain)_______________________________________________________.
40. Psychological Treatment? (if so, please explain)______________________________________________________.
8. 41. Hyperactivity/Attention Deficit? (if so, please explain)_________________________________________________.
42. Have you ever been worried about your weigh or had a history of any eating disorders? Ex. Anorexia Nervosa or
Bulimia? (if so, please explain)___________________________________________________________________.
43. Do you have a family member who has been diagnosed with cancer? (if so, please
explain)______________________________________________________________________________________.
44. Pneumonia? (if so, please explain)_________________________________________________________________.
45. Thyroid Problems? (if so, please explain)____________________________________________________________.
46. Chicken Pox (if so, please explain) _________________________________________________________________.
47. Fainting? (if so, please explain)_____________________________________________________________________.
48. Recent or Chronic Infections? (if so, please explain)____________________________________________________.
49. Frequent Sore Throats? (if so, please explain)_________________________________________________________.
50. Frequent Ear Infection? (if so, please explain and list how many)__________________________________________.
51. Frequent Bronchitis? (if so, please explain)___________________________________________________________.
52. Frequent Nose Bleeds? (if so, please explain and list how many)__________________________________________.
53. Motion Sickness? (if so, please explain)______________________________________________________________.
54. Scoliosis? (if so, please explain)____________________________________________________________________.
55. Hearing Impairment? (if so, please explain)___________________________________________________________.
56. Wears any sort of corrective lenses. Ex. Glasses or contacts (if so, please explain) ____________________________.
57. Premature Birth or Problems at Birth? (if so, please explain)______________________________________________.
58. Any Major Surgeries? (if so, please explain)__________________________________________________________.
59. Any Major Injuries? (if so, please explain)____________________________________________________________.
60. Tuberculosis? (if so, please explain)________________________________________________________________.
61. Rheumatic Fever? (if so, please explain)______________________________________________________________.
62. Sickle Cell Anemia? (if so, please explain)____________________________________________________________.
63. Any other pertinent conditions not listed above? (if so, please explain)______________________________________.
Females only:
64. Have you ever had a menstrual period? (if so, please list the date of your last cycle)___________________________.
65. How old were you when you had your first period? ____________________________________________________.
66. How many periods have you had in the last 12 months? _________________________________________________.
I hereby state that, to the best ofmy knowledge, my answers to the above questions are complete and correct.
Signature of Athlete_________________________________________ Date: __________________
Signature of Parent and/or Guardian___________________________________________ Date:__________________
To be signed and completed by athlete
9. Clarion Area High School Physical Examination Form
(To be filled out by physician)
Student’s Name_____________________________ Type of Sport___________________ Date: ___/___/___
Height_________ Weigh: ____________ Pulse___________ Blood Pressure_________ / __________
Visual Acuity: Right 20/_____ Left 20/_____ Corrected: Yes / No Pupils Equal: ______ Unequal ______
FINDINGS NORMAL PHYSICIAN NOTES
MEDICAL
1. Appearance ____________________ __________________________________
2. Eyes/Ears/Nose/Throat ____________________ __________________________________
3. Lymph Nodes ____________________ __________________________________
4. Heart ____________________ __________________________________
5. Pulses _____________________ __________________________________
6. Lungs _____________________ __________________________________
7. Abdomen _____________________ __________________________________
8. Genitalia (males only) _____________________ __________________________________
9. Skin _____________________ __________________________________
10. Urinalysis _____________________ __________________________________
11. History of Concussions _____________________ __________________________________
MUSCULOSKELETAL
1. Neck _______________________ __________________________________
2. Back _______________________ __________________________________
3. Shoulder/Arm ________________________ __________________________________
4. Elbow/Forearm ________________________ __________________________________
5. Wrist/Hand ________________________ ___________________________________
6. Hip/Knee ________________________ ___________________________________
7. Knee ________________________ ___________________________________
8. Leg ________________________ ___________________________________
9. Foot ________________________ ___________________________________
ASSESSMENT
_____ Cleared without limitation
Cleared after completing evaluation/ rehabilitation for_____________________________________________.
______ NOT CLEARED for: _____________________________ Reason: _____________________________
_________________________________________________________________________________________.
11. Justification Paper
Each year, between seventeen and twenty-five million adolescents engage in some type of sports related
activity, and each year more than two million injuries occur requiring doctor’s visits and hospitalizations. Since
August of 2010, at least fourteen high school and youth football players have died during or a result of athletic
participation. One of the most important aspects of preventing injury or sudden death in athletes is detecting
any underlying health problems before the athlete begins participation. Some of the main questions that the
medical history form asks the athlete is information regarding both themselves, and their family members. The
reason for this, is that sometimes diseases or health problems are passed down through generations, and the
athlete could be unaware of them. A thorough medical history can reveal up to seventy-five percent of
conditions that would limit or alter sports participation, and in conjunction with a musculoskeletal testing most
athletes do prove to be very healthy. The questions that are asked are all inclusive and hit the major categories
such as psychological issues, eating disorders, medications, past concussions, previous surgeries, allergies,
heart-health problems, and even past musculoskeletal injuries. The medical aspect of the physical form that is to
be completed by a physician is to make sure that the athlete has healthy vitals, the athletes vision is correct, and
the major systems of the body are all functioning properly (i.e. respiratory, circulatory, etc.). The
musculoskeletal aspect of the physical form is to detect any mechanical abnormalities in the joints from past
injuries, or any weakness that may predispose the athlete to injury for the upcoming season. Only about three to
thirteen percent of all athletes who participate in a pre-participation exams require further evaluation, but it can
make all the difference if a medical emergency were to occur.
The other forms include the medical release form which states that the parent and/or guardian is granting
the physician, certified athletic trainer, and all associated medical staff ability to treat the athletes to the best of
their abilities. This is crucial for all the medical staff to make sure that law suits do not arise from any claims of
malpractice. The student-athlete information card that gives the athletic trainer the ability to access any
pertinent information if the athlete were to ever have to go to the emergency room or hospital. Also, the
athlete’s address is provided in case there were to be any billing information, or doctor’s notes that needed to be
sent to the athlete’s parent and/or guardian. The next form is the emergency contact information which is
utilized in situations where there may be a medical emergency and the athlete’s parent and/or guardian needs to
be informed; Three contacts are to be given in case the first two are not reachable at the time of emergency.
The insurance verification form is just that, a way for the athletic trainer to send any information to physicians
or hospitals for billing services, and to ensure that the athlete is covered in case an injury is to occur. All
information on the insurance card should be filled out in the lines provided, in addition to a photo-copy of the
insurance card itself. All of these forms are very crucial to the pre-participation exam, and are created to help
the certified athletic trainer provide the best care for the athlete and prevent injury from occurring.
