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City Address City / / Company Yes No Limited / / Facility American College of Sports Medicine / / IndustryTerm assistive device / unexplained car accident / / MedicalCondition myopia / Allergies / hypertrophic cardiomyopathy / taken asthma / Brugada syndrome / headaches / unexplained seizures / joint injury / cancer / catecholaminergic polymorphic ventricular tachycardia / arrhythmogenic right ventricular cardiomyopathy / heart infection / disease / headache / pressure sores / arachnodactyly / eye injuries / unexplained fainting / MRSA skin infection / seizure disorder / tinea corporis Neurologic / Diabetes / herpes / dwarfism / pectus excavatum / juvenile arthritis / hernia / short QT syndrome / pain / High cholesterol / numbness / injury / Marfan syndrome / specific allergy / eating disorder / High blood pressure / sickle cell trait / infectious mononucleosis / muscle cramps / sudden infant death syndrome / unexplained seizure / connective tissue disease / 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 / IHSA Board of Directors / American Medical Society for Sports Medicine / American Academy of Pediatrics / American Orthopaedic Society for Sports Medicine / / Position Signature Physician / athlete / Physician / Advanced Nurse / Assistant Signature* Advanced Nurse / / Technology x-ray / Sports Medicine / MRI / / URL www.IHSA.org / http / SocialTag 
Pre-participation Examination To be completed by athlete or parent prior to examination. Name School Year Last