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 American Osteopathic Academy of Sports Medicine THE AUTHORITATIVE RESOURCE FOR ATHLETIC SCREENING PREPARTICIPATION PHYSICAL EVALUATION 5th Edition PPE GENERAL QUESTIONS (Explain “Yes” answers at the end of this form. Circle questions if you don’t know the answer.) Yes No 1. Do you have any concerns that you would like to discuss with your provider? 2. Has a provider ever denied or restricted your participation in sports for any reason? 3. Do you have any ongoing medical issues or recent illness? HEART HEALTH QUESTIONS ABOUT YOU Yes No 4. Have you ever passed out or nearly passed out during or after exercise? 5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? 6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? 7. Has a doctor ever told you that you have any heart problems? 8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography. PREPARTICIPATION PHYSICAL EVALUATION HISTORY FORM Note: Complete and sign this form (with your parents if younger than 18) before your appointment. Name: ________________________________________________________________ Date of examination: _______________________________ Sex assigned at birth (F, M, or intersex): _________________ List past and current medical conditions. ________________________________________________________________________________________________other):orM,(F,gender?youridentify__________________________________________________________________________________birth:ofDateyoudoSport(s):How _______________________________________________________________________________________________________________ Have you ever had surgery? If yes, list all past surgical procedures. _______________________________________________________ _______________________________________________________________________________________________________________ Medicines and supplements: List all current prescriptions, over-the-counter medicines, and supplements (herbal and _______________________________________________________________________________________________________________nutritional). _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________insects).stingingfood,pollens,medicines,(ie,allergiesyouralllistpleaseyes,Ifallergies?anyhaveyouDo _______________________________________________________________________________________________________________ Patient Health Questionnaire Version 4 (PHQ-4) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle response.) Not at all Several days Over half the days Nearly every day Feeling nervous, anxious, or on edge 0 1 2 3 Not being able to stop or control worrying 0 1 2 3 Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 (A sum of 3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.) HEART HEALTH QUESTIONS ABOUT YOU (CONTINUED) Yes No 9. Do you get light-headed or feel shorter of breath than your friends during exercise? 10. Have you ever had a seizure? HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)? 12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic poly- morphic ventricular tachycardia (CPVT)? 13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35? The fifth edition of this best-selling resource provides practical guidance for determining athletic medical ­ eligibility, optimizing sports participation safety, and promoting healthy lifestyles. Developed by leading medical societies, PPE: ­ Preparticipation Physical Evaluation guides health care professionals through the preparticipation physical evaluation (PPE) process in the medical home for young athletes from middle school through college. This newly revised and expanded edition is adaptable for a wide range of individual or institutional needs. New in the Fifth Edition New chapter on transgender athletes New chapter on female athletes New section on mental health Incorporating PPE into routine health supervision care Updated content based on the most current ­ practice guidelines, ­consensus statements, and expert opinions Developed to enhance the health and safety of all athletes and establish a standardized ­ approach to PPE English and Spanish versions of the History Form Topics include System-based examination: cardiovascular, nervous system, respiratory, gastrointestinal and urogenital, dermatologic, musculoskeletal, mental health, and more Preparticipation physical evaluation timing, setting, and structure Medical history ­ questions Medical eligibility ­ considerations Return to play ­ guidelines Medicolegal and ­ ethical concerns Future research needs Plus much more… For other pediatric resources, visit the American Academy of Pediatrics at shop.aap.org. EASY-TO-USE PREPARTICPATION PHYSICAL EVALUATION FORMS History Form (English and Spanish versions) Physical Examination Form Athletes With Disabilities Form: Supplement to the Athlete History Medical Eligibility Form PREPARTICIPATION PHYSICAL EVALUATION 5th Edition PPE 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 American Osteopathic Academy of Sports Medicine AAP PPE PREPARTICIPATION PHYSICAL EVALUATION 5th Edition
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