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Facility College of Sports Medicine / American College of Sports Medicine / / IndustryTerm assistive device / unexplained car accident / / MedicalCondition myopia / Allergies / taken asthma / hypertrophic cardiomyopathy / Brugada syndrome / headaches / unexplained seizures / joint injury / catecholaminergic polymorphic ventricular tachycardia / arrhythmogenic right ventricular cardiomyopathy / disease / heart infection / headache / pressure sores / Easy bleeding Enlarged spleen Hepatitis Osteopenia / arachnodactyly / hypothermia / eye injuries / unexplained fainting / MRSA skin infection / seizure disorder / tinea corporis Neurologic / Diabetes / herpes / dwarfism / frequent seizures / pectus excavatum / hernia / juvenile arthritis / short QT syndrome / numbness / High cholesterol / pain / injury / Marfan syndrome / specific allergy / eating disorder / sickle cell trait / High blood pressure / infectious mononucleosis / muscle cramps / sudden infant death syndrome / illness / autonomic dysreflexia / hearing loss / unexplained seizure / DO EMERGENCY INFORMATION Allergies / connective tissue disease / muscle spasticity / bladder Numbness / Anemia / syndrome / head injury / Asthma / long QT syndrome / / MedicalTreatment surgery / / Organization American College of Sports Medicine / American Academy of Family Physicians / Sports Medicine / and American Osteopathic Academy of Sports Medicine / American Medical Society for Sports Medicine / American Academy of Pediatrics / American Orthopaedic Society for Sports Medicine / / Position athlete / physician / / Technology x-ray / Sports Medicine / MRI / / SocialTag 
■■ Preparticipation Physical Evaluation HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.) Date of Exam