GUIDE: How to Fill Out the UIL Pre-Participation Medical History Form

UIL PRE-PARTICIPATION PHYSICAL EVALUATION 

STEP-BY-STEP GUIDE TO COMPLETE THE MEDICAL HISTORY FORM

TABLE OF CONTENTS 

⃝ About Adolescent Sports Metrics 

⃝ Before You Begin… 

⃝ About Medical History Form 

• Top Section Instructions 

• Instructions for Questionnaire 

• “YES” Answer Explanation Box 

• Question #1 


• Question #3A 

• Question #3B • Question #3G 

• Question #3C • Question #3H 

• Question #3D • Question #3I 

• Question #3E • Question #3J 

• Question #3F • Question #3K 


• Question #4B 

• Question #4C 

• Question #4D 

• Question #4E 

• Question #4F 








Question #12 

Question #13A 

• • Question #13B 

• • Question #13C 








⃝ Notes about Question #19 

• Question #19A (FEMALES ONLY) 



• Question #20 (MALES ONLY) 

• Question #21 (MALES ONLY) 

⃝ Disclosure & Consent Information 

⃝ Back Page - Medical History Form 

©2019 Adolescent Sports Metrics 501(c)(3)

10 Medical Parkway | Plaza 3, Suite 201 | Farmers Branch, TX 75234 | (469) 657-5244 

Adolescent Sports Metrics (ASM) is a 501 (c)(3) nonprofit organization founded in 2017. ASM’s mission is to collect data from 

young athletes during UIL Pre-Participation Evaluations in order to establish what “normal” looks like in this demographic 

group. “Normal” data ranges are not currently available for various reasons, primarily because this age group does not see 

healthcare providers unless ill. As a result, the data collected during sick visits do not improve diagnoses for providers or 

outcomes for patients. By allowing ASM to serve your children, you allow us to serve everyone's in the future with better data, 

for better research and better futures. 

Website: www.AdolescentSportsMetrics.org Facebook: @ASMetrics Twitter: @ASportsMetrics 


BEFORE YOU BEGIN… 

UIL PRE-PARTICIPATION EVALUATION - MEDICAL HISTORY FORM FACTS 

The information provided in this presentation is not in lieu of medical advice. This step-by-step guide was created to help Coaches, 

Parents/Guardians and Students complete the UIL Pre-Participation Medical History Form. 

The purpose of the UIL Pre-Participation Physical & Medical History Form is not to exclude a child from sport-related activities, but to 

make participation safe and to alert the parent/guardian of any health care issues that may arise. 

▪ 

▪ 

▪ 

Parent/Guardian should complete the Medical History Form with the child present. The child may be able to answer some of the questions or 

provide necessary information that the parent/guardian is not currently aware of or privy to. 

If a child has a chronic health care condition that is currently being treated by a physician, a school sponsored group physical is NOT the appropriate 

place for that child to obtain his/her UIL Pre-Participation Physical. The child should visit and obtain his/her physical from the treating physician. The 

treating physician’s written approval is required for the child’s participation in any sport-related activity. 

If you answer “YES” to question #5 on the Medical History Form, “Are you missing any paired organs?” (for example, a lung or kidney), a school 

sponsored group physical is NOT the appropriate place for your child to obtain his/her UIL Pre-Participation Physical. A Clearance Letter from a 

Specialist allowing the child to participate in a sport-related activity will be required. 

For those planning to visit a Primary Care Physician to obtain their child’s physical: 

1. The UIL Pre-Participation Physical Evaluation must be completed prior to tryouts for any school sponsored, sport-related activity. 

2. The physical must NOT be completed and dated prior to April 1 st . However, district rules can supersede that date, in which case, the date becomes 

May 1 st of the previous school year. 

3. UIL states on their forms and website that a Physical Evaluation is only needed every 2 years. However, district rules require an annual Physical 

Evaluation to participate in athletics, practices or games. 

4. If you plan to use your insurance and one annual wellness exam with child’s primary care physician to obtain child’s physical, please schedule your 

visit/physical during the first 2 weeks of May. 

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ABOUT THE MEDICAL HISTORY FORM 

UIL PRE-PARTICIPATION EVALUATION 

MEDICAL HISTORY FORM 

must be completed annually 

by parent (or guardian) and 

student in order for the 

student to participate in 

athletic activities. These 

questions are designed to 

determine if the student has 

developed any condition 

which would make it 

hazardous to participate in an 

athletic event. 

Click the red icon to 

download the form or 

visit the UIL website. 

PAGE 1 PAGE 2 

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TOP SECTION INSTRUCTIONS 

UIL PPE – MEDICAL HISTORY FORM 

▪ Student’s parent or guardian should fill out the top section of the form and print legibly. If 

a student requires a referral and the information in this section cannot be read, the 

student’s referral and therefore, eligibility to participate in athletic activities, may be 

delayed. 

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INSTRUCTIONS FOR QUESTIONNAIRE 


Explain “Yes” answers in the box below**. Circle questions you 

don’t know the answers to. 

▪ ALL “Yes” answers must be fully explained (with necessary details – date or age of occurrence, 

situation explanation, family medical history, etc.) in the box under the last question, #21. Attach 

another piece of paper to the Medical History Form if more space is needed to explain any “Yes” 

answers for questions #1 - #21. 

▪ Circle all questions the student or parent/guardian cannot answer. 

▪ If a student is adopted and history is unknown please answer all questions to the best of your 

ability. Then state in the explanation box the student is adopted and family history is unknown. 

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“YES” 

ANSWERS 

EXPLANATION 

BOX 

Box for further explanation of any 

and all “Yes” answers located at 

bottom of page 1 on the Medical 

History Form under question #21. 

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QUESTION #1 


1. Have you had a medical illness or injury since your last check 

up or sports physical? 

▪ Answer “YES” if student has had any type of medical illness or injury in the past 12 

months (since last annual UIL physical or 1 year prior to date of current UIL physical). 

▪ Which was it: Illness or Injury? Circle one or both if appropriate and fully explain. 

▪ “Medical illness or injury” refers to any form of sickness or physical injury severe enough to require 

hospitalization or continued treatment by a healthcare provider (e.g., 

▪ Broken bone(s) 

▪ Surgery of any kind 

▪ Communicable Diseases (Measles, Hepatitis, STDs, HIV/AIDS, Tetanus, etc.) 

▪ Recent diagnoses (asthma, congenital conditions, etc.) 

▪ Fully explain the situation surrounding the illness or injury, duration, recommended treatment, and include 

any other necessary details in the explanation box after question #21. 

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QUESTION #2 


2. Have you been hospitalized overnight in the past year? 

Have you ever had surgery? 

▪ TOP QUESTION: Answer “YES” if student has had to spend a night in the hospital for any reason 

over the past year (since last annual UIL physical or 1 year prior to date of current UIL physical). 

▪ Fully explain the situation and any necessary details of the overnight hospital stay in the explanation box after 

question #21. 

▪ BOTTOM QUESTION: Answer “YES” if student has had a surgery of any kind at any point in their 

lifetime. 

▪ Fully explain the situation surrounding the surgery and why it was necessary. Include any other necessary 

details of the surgery in the explanation box after question #21. 

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QUESTION #3A 


3. Have you ever had prior testing for the heart ordered by a 

physician? 

▪ Answer “YES” if student has had one or more heart tests ordered (even if testing wasn’t actually 

performed) by a physician at any point in their lifetime. 

▪ Heart Tests Include: Angiography, Blood Pressure Monitoring, Blood Tests, Echocardiogram (echo), 

Electrocardiograph (ECG), Electrophysiological Studies, Myocardial Perfusion Scans & Tilt Table Test. 

▪ If you’ve had surgery, then you’ve had heart monitoring while in the hospital for surgery. Heart 

monitoring is NOT heart testing. The question is: Has any doctor ordered tests specifically on 

your heart? 

▪ If “YES”, fully explain why heart tests were ordered, what the results were and include any other 

necessary details in the explanation box after question #21. 

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QUESTION #3B 


3. Have you ever passed out during or after exercise? 

▪ Answer “YES” if student has ever fainted/passed out (even if only for a few seconds) 

during or immediately after exercise at any point in their lifetime. 

▪ Which was it: During or After? Circle one or both if appropriate and fully explain. 

▪ Fully explain the situation surrounding the fainting episode. What type of exercise? Did you seek 

medical attention? What was the outcome? How often do you pass out with exercise? Include 

any other necessary details in the explanation box after question #21. 

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QUESTION #3C 


3. Have you ever had chest pain during or after exercise? 

▪ Answer “YES” if student has ever had obvious chest pains during or immediately after 

exercise at any point in their lifetime. 

▪ Which was it: During or After exercise? Circle one or both if appropriate and fully 

explain. 

▪ Fully explain the situation surrounding the chest pains episode(s). What type of exercise? Did you 

seek medical attention? What was the outcome? How often do you have chest pain with 

exercise? Include any other necessary details in the explanation box after question #21. 

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QUESTION #3D 


3. Do you get tired more quickly than your friends do during 

exercise? 

▪ Answer “YES” if student has trouble keeping up with the physical performance level of 

other kids his/her age including more severe than expected shortness of breath, 

coughing or wheezing symptoms during exercise. 

▪ Fully explain the situation surrounding the student’s inability to maintain an average physical 

performance level comparative to peers. What type of exercise? How often does this occur? 

Include any other necessary details in the explanation box after question #21. 

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QUESTION #3E 


3. Have you ever had racing of your heart or skipped 

heartbeats? 

▪ Answer “YES” if student has ever had heart palpitations (skipping beats, fluttering 

rapidly, beating too fast, pounding or flip-flopping) felt in the throat, neck or chest at 

any point in their lifetime. 

▪ Fully explain the situation/environment leading up to and during the heart palpitations. Did you 

seek medical care for the palpitations? If so, when & where did you seek medical attention? 

What was the outcome? Include any other necessary details in the explanation box after question 

#21. 

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QUESTION #3F 


3. Have you had high blood pressure or high cholesterol ? 

▪ Answer “YES” if student has ever been diagnosed with high blood pressure or high 

cholesterol by a healthcare provider at any point in their lifetime. 

▪ Which was it: High Blood Pressure or High Cholesterol? Circle one or both if 

appropriate and fully explain. 

▪ Fully explain the situation/environment leading up to and during the diagnosis. Were you 

medicated? Have you been released? Include any other necessary details (such as doctor 

recommendations for treating condition) in the explanation box after question #21. 

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QUESTION #3G 


3. Have you ever been told you have a heart murmur? 

▪ Answer “YES” if student has ever been diagnosed with a heart murmur by a healthcare 

provider at any point in their lifetime. 

▪ A Heart Murmur is an unusual sound heard between heartbeats. Murmurs sometimes sound like a 

whooshing or swishing noise. 

▪ Fully explain the situation/environment leading up to and during the heart murmur diagnosis. 

When was it diagnosed? When was the last time you were seen for it? If you have been cleared, 

you MUST provide that clearance documentation. Include any other necessary details in the 

explanation box after question #21. 

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QUESTION #3H 


3. Has any family member or relative died of heart problems or 

of sudden unexpected death before age 50? 

▪ Answer “YES” if student knows he or she has a family history (any blood relative) of 

heart problems and sudden unexpected death. 

▪ Fully explain the situation (when the parent/student learned the family history information and 

who provided that information). Which side of the family has the history of heart problems 

(mother’s or father’s side)? Was it your mother/father that had the heart problem? Include any 

other necessary details in the explanation box after question #21. 

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QUESTION #3I 


3. Has any family member been diagnosed with enlarged heart 

(dilated cardiomyopathy), hypertrophic cardiomyopathy, long QT 

syndrome or other ion channelopathy (Brugada syndrome, etc.) 

Marfan’s syndrome, or abnormal heart rhythm? 

▪ Answer “YES” if student knows he or she has a family history of any of the following: 

▪ Enlarged Heart – heart’s ability to pump blood decreased because left ventricle enlarged & weakened. 

▪ Hypertrophic Cardiomyopathy – disease in which heart muscle becomes abnormally thick. 

▪ Long QT Syndrome (LQTS) – condition affecting repolarization of heart after heartbeat. Higher risk of irregular heartbeat possibly 

resulting in palpitations, fainting, drowning or sudden death. 

▪ Ion Channelopathies – diseases caused by disturbed function of ion channel 

▪ Brugada Syndrome – heart rhythm disorder that is sometimes inherited. 

▪ Marfan Syndrome – genetic disorder affecting body’s connective tissue (often in heart) 

▪ Abnormal Heart Rhythm – heart rate too fast, too slow or irregular. 

▪ Fully explain the situation (when the parent/student learned the family history information and who 

provided that information). Who was the family member diagnosed? Include any other necessary 

details in the explanation box after question #21. 

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QUESTION #3J 


3. Have you had a severe viral infection (for example, 

myocarditis or mononucleosis) within the last month? 

▪ Answer “YES” if student was diagnosed with severe viral infection within last 30 days. 

▪ Myocarditis – inflammation of the heart muscle that can affect heart muscle & heart’s electrical 

system reducing its ability to pump and causing rapid or abnormal heart rhythms (arrhythmias). 

▪ Mononucleosis (mono or “the kissing disease”) - infectious illness spread through bodily fluids, 

usually mild fatigue symptoms but can lead to complications that can make it more dangerous. 

▪ Fully explain the situation surrounding diagnosis and include any other necessary details (such as 

severity, complications, etc.) in the explanation box after question #21. 

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QUESTION #3K 


3. Has a physician ever denied or restricted your participation 

in sports for any heart problems? 

▪ Answer “YES” if student has ever been told to avoid sport activities by a physician for 

any type of heart related problem(s) at any point in their lifetime. 

▪ Fully explain the situation, the type of heart problem(s) diagnosed and reason for restricted 

physical activity. Provide the treating doctor’s documented release to participate in sports. 


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QUESTION #4A 


4. Have you ever had a head injury or concussion? 

▪ Answer “YES” if student has ever had a concussion (injury to the brain resulting in 

temporary loss of normal brain function) or injured their head in any way at any point 

in their lifetime. 

▪ Fully explain the situation surrounding the injury and any symptoms experienced. Were you 

treated by a medical provider? If so, what was the diagnosis and/or recommended treatment? 


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QUESTION #4B 


4. Have you ever been knocked out, become unconscious, or lost your memory? 

If yes, how many times? 

fill in blank 

When was your last concussion? 

fill in blank 

How severe was each one? (Explain below) 

▪ Answer “YES” if student has ever experienced a knock-out blow (a concussion or traumatic brain injury) or loss of 

memory, even for a few seconds, after injuring their head in any way at any point in their lifetime. 

▪ 

▪ If “YES”, fill in the blank with the number of times the student has experienced a knock-out blow and/or memory loss. 

▪ Fill in the blank with the full date (mm/dd/yyyy) of student’s last concussion. 

▪ How severe was each concussion experienced by student? Answer the following questions for each concussion 

experienced in the Explanation Box below question #21: Length of time student was unconscious? Was internal 

bleeding or swelling present? Any noticeable & lasting behavioral or cognitive changes? How long was student out for 

recovery? 

Fully explain the situation surrounding the knock-out blow/injury, any symptoms experienced, length of time student 

was unconscious, length of time student was out for recovery, diagnosis and/or recommended treatment, number of 

knock-out blows experienced, date of last concussion and include any other necessary details in the explanation box 

after question #21. 

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QUESTION #4C 


4. Have you ever had a seizure? 

▪ Answer “YES” if student has ever experienced a sudden, uncontrolled electrical 

disturbance in the brain causing changes in behavior, movements or feeling & in levels 

of consciousness at any point in their lifetime. 

▪ If student has had anything other than a febrile seizure (convulsion caused by a fever or 

spike in body temperature) as an infant/toddler, a release from the treating 

neurologist will be required for student to participate in sports. 

▪ Fully explain the situation surrounding the seizure, any symptoms experienced, length of time 

seizure lasted, diagnosis and/or recommended treatment, and include any other necessary details 

in the explanation box after question #21. 

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QUESTION #4D 


4. Do you have frequent or severe headaches? 

▪ Answer “YES” if student is currently experiencing headaches of any kind due to a recent 

concussion. 

▪ Fully explain the situation surrounding the headaches. If you are female: Do the headaches occur 

around your menstrual cycle? Do you drink enough water? Do you eat healthy foods? Do you 

wear glasses? How often do the headaches occur (1 per month, 1 per week, etc.)? Describe 

“severe” on a scale of 1 to 10 (1 being low pain and 10 being extreme pain). Is medication 

needed? If so, what medication do you take to manage the pain/headaches? Include the length 

of time the headaches typically last, diagnosis and/or recommended treatment, and any other 


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QUESTION #4E 


4. Have you ever had numbness or tingling in your arms, hands, 

legs or feet? 

▪ This question is NOT asking if your hands or feet fall asleep when you sit on them for an 

extended period of time. It IS asking if your hands or feet randomly feel tingly and/or 

funny while you are using them (running, walking, writing, carrying something, etc.). 

▪ Answer “YES” if student has ever experienced a tingling sensation or numbness in their 

arms, hands, legs or feet at any point in their lifetime after a concussion or head 

injury. 

▪ Fully explain the situation surrounding the tingling or numbness sensations, which extremities 

affected, length of time sensations typically lasted, severity of tingling or numbness on a scale of 1 

to 10 (1 being low pain and 10 being extreme pain), diagnosis and/or recommended treatment, 

and include any other necessary details in the explanation box after question #21. 

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QUESTION #4F 


4. Have you ever had a stinger, burner, or pinched nerve? 

▪ If you don’t know what these are, answer “NO” because you have never had one. 

▪ Answer “YES” if student has ever experienced a burner, stinger or pinched nerve at any 

point in their lifetime after a concussion or head injury. 

▪ Burners & Stingers are injuries that occur when nerves in the neck and shoulders are stretched or compressed after and 

impact. They can feel like an electric shock or lightning bolt down the arm. 

▪ A pinched nerve occurs when too much pressure is applied to a nerve by surrounding tissue, such as bones, cartilage, 

muscles or tendons. The pressure disrupts the nerve’s function causing pain, tingling, numbness or weakness. 

▪ Fully explain the situation surrounding the pain/sensations experienced, describe the pain/sensation 

(burning, stinging, weakness, etc.), length of time sensations typically lasted, severity of sensations on a 

scale of 1 to 10 (1 being low pain and 10 being extreme pain), diagnosis and/or recommended 

treatment, and include any other necessary details in the explanation box after question #21. 

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QUESTION #5 


5. Are you missing any paired organs? 

▪ Answer “YES” if student is missing or has had any paired organs surgically removed at any point 

in their lifetime. 

▪ Paired organs include: ears, eyes, lungs, kidneys, ovaries, or testes. 

▪ If answer is “YES,” then a school sponsored group physical is NOT the appropriate place for the 

student to obtain his/her UIL Pre-Participation Physical. The UIL is very clear about missing 

paired organs such as a kidney or lung. You must have Pulmonary (lung doctor) or Nephrology 

(kidney doctor) clearance to participate in a sport-related activity. 

▪ Fully explain the situation surrounding the missing and/or removed organ, describe any related 

illness, injury or birth defect resulting in the missing organ, diagnosis and/or recommended 

treatment and include any other necessary details in the explanation box after question #21. 

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QUESTION #6 


6. Are you under a doctor’s care? 

▪ This question is NOT asking if the student has a doctor. 

▪ Answer “YES” if student is currently being treated by a physician for a medical 

condition (illness, injury, etc.). Only answer “YES” if student is in the middle of receiving 

treatment for a medical condition from a doctor. 

▪ If student answers “YES”, then a school sponsored group physical is NOT the appropriate 

place for the student to obtain his/her UIL Pre-Participation Physical. When the 

treatment/care has been completed, then the student can get a physical. 

▪ Fully explain the situation surrounding the medical condition (illness, injury, etc.) currently being treated, 

describe the diagnosis and/or recommended treatment, length of time affected by medical condition 

and include any other necessary details in the explanation box after question #21. 

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QUESTION #7 


7. Are you currently taking any prescription or non-prescription 

(over-the-counter) medication or pills or using and inhaler? 

▪ Answer “YES” if student is currently taking any prescription or non-prescription 

medication or pills (such as pain relievers, allergy or cold/cough medicines, sleeping 

pills, anti-depressants, stimulants like Adderall or vitamins) or regularly using an inhaler 

for treatment of asthma. 

▪ Which is it: Prescription or Non-Prescription? Circle one or both if appropriate and fully explain. 

▪ Fully explain the situation surrounding the medical condition (illness, injury, allergy, depression, asthma, etc.) 

the student or primary care physician is treating with prescription or OTC pills and/or an inhaler. What 

medication(s) are you taking? Why are you taking the medication(s)? What is the dosage? Describe the 

diagnosis and/or recommended treatment, length of time affected by medical condition and include any 

other necessary details in the explanation box after question #21. 

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QUESTION #8 


8. Do you have any allergies (for example, to pollen, medicine, 

food, or stinging insects)? 

▪ Answer “YES” if student has any known allergies to pollen (seasonal), any type of food, 

any medicines or stinging insects (bees, wasps, or ants). 

▪ Fully explain the allergy (what causes the allergic reaction), the severity of the reaction and 

recommended treatment. Do you have an EpiPen? Include any other necessary details in the 


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QUESTION #9 


9. Have you ever been dizzy during or after exercise? 

▪ Answer “YES” if student has ever consistently felt dizzy during or after exercise 

(especially light exercise) at any point in their lifetime. Consistent light-headedness or 

dizziness during or immediately after even light exercise could be caused by an 

underlying heart problem. 

▪ Which is it: During or After? Circle one or both if appropriate and fully explain. 

▪ Fully explain the situation surrounding the dizziness spell(s). What type of exercise? Was student 

hydrated and had they eaten that day? Describe the diagnosis and/or recommended treatment, 

number of times the student has experienced dizziness during or after exercise, severity of 

symptoms and include any other necessary details in the explanation box after question #21. 

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QUESTION #10 


10. Do you have any current skin problems (for example, 

itching rashes, acne, warts, fungus, or blisters)? 

▪ Answer “YES” if student currently has any severe or unusual skin conditions. 

▪ Some skin conditions are contagious (STDs, fungal infections, etc.). Severe acne might 

be treated with medications (such as Accutane) that can cause noticeable side effects 

that may explain other issues or conditions. Certain skin problems can signal a heart 

problem as well. 

▪ Fully explain the situation surrounding any skin conditions student is currently suffering from, how 

long student has had the skin condition and whether or not student is being treated by a doctor or 

is taking medications to treat the skin condition. Include any other necessary details in the 


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QUESTION #11 


11. Have you ever become ill from exercising in the heat? 

▪ Answer “YES” if student has ever gotten sick (weakness, vomiting, muscle cramps, 

headache, heavy sweating, dizziness, etc.) while exercising in the heat. 

▪ Fully explain the situation surrounding the heat sickness. What type of symptoms did you 

experience? How hot was it that day? What did you eat and/or drink that day? If you sought 

medical care, what was the diagnosis and/or recommended treatment? How many times have 

you experienced heat sickness? Include any other necessary details in the explanation box after 

question #21. 

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QUESTION #12 


12. Have you had any problems with your vision or eyes? 

▪ Answer “YES” if student has ever had vision problems (sudden or recurrent eye pain, 

hazy, blurred or double vision, flashes of light, rainbows or halos around lights, etc.) at 


▪ Nearsightedness – objects up close appear clearly while objects far away appear blurry 

▪ Farsightedness – distant objects may be seen more clearly than objects that are near 

▪ Astigmatism – images appear blurry and stretched out 

▪ Fully explain the situation surrounding the vision or eye problem(s). Have you been to an 

Optometrist or Ophthalmologist (eye doctor)? What was the diagnosis or recommended 

treatment? Have you been prescribed eye glasses or contacts? Include any other necessary 


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QUESTION #13A 


13. Have you ever gotten unexpectedly short of breath with 

exercise? 

▪ Answer “YES” if student has ever experienced exercise-induced shortness of breath at 


▪ Fully explain the situation surrounding the shortness of breath. What type of exercise? How long 

had you been exercising? Did you seek medical care? If so, what was the diagnosis or outcome? 


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QUESTION #13B 


13. Do you have asthma? 

▪ Answer “YES” if student has been diagnosed by a health care provider with asthma. 

▪ Asthma – A chronic disease causing the airways (bronchial tubes) in the lungs to become inflamed and swollen. 

The muscles around the airways can tighten when something triggers your symptoms. 

▪ Fully explain the situation surrounding an asthma attack. How often do your asthma attacks 

occur? How long do the attacks usually last? Do you have or regularly use a rescue inhaler? If 

you do NOT have an inhaler, when was your last asthma attack? Include any other necessary 


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QUESTION #13C 


13. Do you have seasonal allergies that require medical 

treatment? 

▪ Answer “YES” if student has allergies that require medical treatment (prescription or 

non-prescription antihistamines, decongestants, nasal spray, etc.). 

▪ Fully explain the situation surrounding need for medical treatment of seasonal allergies. What 

type of medical treatment do you take/use? Was it prescribed or is it over-the-counter? How 

often do you take the medicine to treat your allergies? Include any other necessary details in the 


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QUESTION #14 


14. Do you use any special protective or corrective equipment or devices that 

aren’t usually used for your sport or position (for example, knee brace, 

special neck roll, foot orthotics, retainer on your teeth, hearing aid)? 

▪ Answer “YES” if student regularly wears protective or corrective equipment while 

playing sports. 

▪ Fully explain the situation and/or need to use the equipment or devices. What equipment do you 

use? Is it used to protect or correct? How long have you used the equipment? Include any other 


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QUESTION #15A 


15. Have you ever had a sprain, strain, or swelling after injury? 

▪ Answer “YES” if student has ever had a severe sprain, strain or swelling after an injury. 

▪ Fully explain the situation surrounding the injury. Did you seek medical care (this includes your 

school’s Athletic Trainer)? Did you follow and complete care/rehabilitation? How long were you 

out for recovery? Include any other necessary details in the explanation box after question #21. 

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QUESTION #15B 


15. Have you broken or fractured any bones or dislocated any 

joints? 

▪ Answer “YES” if student has ever fractured (broken) any bones or dislocated (injured) 

any joints at any point in their lifetime. 

▪ Fully explain the situation surrounding the broken bone(s) or dislocated joint(s). What bone did 

you break or joint did you dislocate? How severe was the break or joint injury? How long were 

you out for recovery? Did you follow and complete care/rehabilitation? Include any other 


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QUESTION #15C 


15. Have you had any other problems with pain or swelling in muscles, tendons, 

bones or joints? 

If yes, check appropriate box and explain below: 

Head Elbow Hip 

Neck Forearm Thigh 

Back Wrist Knee 

Chest Hand Shin/Calf 

Shoulder Finger Ankle 

Upper Arm 

Foot 

▪ 

▪ 

▪ 

Answer “YES” if student has ever had recurrent problems with pain or swelling in any muscles, tendons, bones or joints 

at any point in their lifetime. 

Check all the boxes that apply to the areas the student has experienced recurring pain or swelling in. 

Please circle one or both if appropriate and fully explain: Pain or Swelling? AND Muscles, Tendons, Bones or Joints? 

▪ 

Fully explain the situation surrounding the pain or swelling in each box marked. How long have you had problems in the areas 

marked? How severe was the pain or swelling? Did you seek medical care? If so, what was the diagnosis and recommended 

treatment? Did you follow and complete care/rehabilitation? Include any other necessary details in the explanation box after 

question #21. 

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QUESTION #16 


16. Do you want to weigh more or less than you do now? 

▪ Answer “YES” if student would like to lose weight or put on more weight. 

▪ Which is it: More or Less? Please circle and fully explain. 

▪ Fully explain. Why do you want to weight more or less than you currently do? Include any other 


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QUESTION #17 


17. Do you feel stressed out? 

▪ Answer “YES” if student is feeling stressed or currently under a lot of pressure for any 

reason (home life, academics, social, extracurricular actives or sport teams, etc.). 

▪ Fully explain the situation(s) surrounding or causing the stress. Why are you feeling stressed out? 

Do you know what specifically is causing most of your stress (home life/personal reasons, 

death in the family, school, friends, extracurricular activities like sport teams, etc.)? Have you 

sought counseling or medical care? Are you taking any medications to manage your stress? 


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QUESTION #18 


18. Have you ever been diagnosed with or treated for sickle cell 

trait or sickle cell disease? 

▪ Answer “YES” if student has ever been tested for or diagnosed with sickle cell trait or 

sickle cell disease at any point in their lifetime. 

▪ Sickle Cell Trait (SCT) – is NOT a disease. Having SCT means that you have inherited the sickle cell gene from one of your 

parents. There are usually no symptoms of sickle cell disease (SCD). 

▪ Sickle Cell Disease (SCD) – is a group of inherited red blood cell disorders. Your body may have trouble making enough 

new red blood cells to replaced damaged cells leading to a condition called anemia, which can make you feel tired. 

▪ Fully explain the situation surrounding the testing, diagnosis or treatment for sickle cell trait (SCT) or 

disease (SCD). Have you been tested? If so, when? What were the results of testing? If you were 

diagnosed with SCD, did you or are you currently receiving treatment? Include any other necessary 


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NOTES FOR FEMALE ONLY QUESTIONS (#19) 

UIL PREPARTICIPATION EVALUATION - MEDICAL HISTORY FORM 

▪ It may be helpful for female students to regularly track of their monthly 

menstrual cycles by marking the First Day of each cycle (the first day of period 

bleeding) on a calendar. This will allow students to count from the beginning of 

one menstrual period to the next to figure out their cycle lengths. This will also 

allow students to plan ahead and know about what time every month to expect 

their menstrual periods to begin. 

▪ For most women, the average menstrual cycle is 28 days, though it can range from 

21 to 35 days in adult women and still be considered normal. 

▪ In the first year, most girls have at least 4 periods; the second year, at least 6 

periods; and for the 3-5th year, at least 8 periods. Most adult women have 9 to 12 

periods a year. Your period will usually last between 3 and 7 days. 

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QUESTION #19A (FEMALES ONLY) 


19. When was your first menstrual period? fill in blank 

When was your most recent menstrual period? 

fill in blank 

▪ TOP QUESTION: Please fill in the blank with the date (mm/yyyy) of your first menstrual 

period ever. If you have not had your first menstrual period yet, please write N/A in the 

blank. 

▪ BOTTOM QUESTION: Please fill in the blank with the date (mm/dd/yyyy) of the first 

day of your most recent menstrual period (NOT the day it ended). If you do not know 

the date, please write unknown in the blank. 

▪ Menstruation — aka having your period — is when blood and tissue from your uterus comes out of 

your vagina. It usually happens every month. 

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QUESTION #19B (FEMALES ONLY) 


19. How much time do you usually have from the start of one 

period to the start of another? 

fill in blank 

▪ Please fill in the blank with the average number of days between the first day of your menstrual 

period (NOT the day it ends – aka stop bleeding) to the last day before your next menstrual 

period begins (you start bleeding again). If you do not know, please write unknown in the blank. 

▪ To figure out how long your cycle is, start at cycle day 1 of your last menstrual cycle (first day 

you started bleeding) and begin counting (Cycle day 1, 2, 3, 4 and so forth). The Length = 

number of days from cycle day 1 to the last cycle day before you started bleeding again. 

▪ 28 days is an average number, but anywhere between 21 and 35 days is normal. In the first year, most girls have at least 4 

periods; the second year, at least 6 periods; and for the 3-5th year, at least 8 periods. Most adult women have 9 to 12 

periods a year. Your period will usually last between 3 and 7 days. 

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QUESTION #19C (FEMALES ONLY) 


19. How many periods have you had in the last year? fill in blank 

What was the longest time between periods in the last year? 

fill in blank 

▪ TOP QUESTION: Count the number of times you have had a menstrual period (bled) over the 

last 12 months and fill in the blank with that number. If you do not know, please write unknown 

in the blank. 

▪ In the first year, most girls have at least 4 periods; the second year, at least 6 periods; and for the 3-5th year, at least 8 

periods. Most adult women have 9 to 12 periods a year. Your period will usually last between 3 and 7 days. 

▪ BOTTOM QUESTION: Fill in the blank with the longest number of days between periods (first 

day of your last cycle to the first day of your the next cycle) that you experienced in the last 12 

months. If you do not know, please write unknown in the blank. 

▪ 

The menstrual cycle, which is counted from the first day of one period to the first day of the next, isn't the same for every 

woman. Menstrual flow might occur every 21 to 35 days and last two to seven days. For the first few years after 

menstruation begins, long cycles are common. 

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QUESTION #20 (MALES ONLY) 


20. Do you have two testicles? 

▪ Answer “YES” if student has 2 testicles (balls). 

▪ Answer “NO” if student does NOT have 2 testicles (balls). 

▪ The testicles are two small, oval-shaped organs, contained in a sac of skin called the scrotum. They 

hang below the penis. The testicles are sometimes called the testes. They are the main organs of the 

male reproductive system. 

▪ If answer is “NO”, how many testicles (balls) do you have? Why do you not have 2 testicles 

(balls)? Fully explain the situation surrounding the missing testicle. Include any other necessary 


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QUESTION #21 (MALES ONLY) 


21. Do you have any testicular swelling or masses? 

▪ Answer “YES” if student has any testicular/scrotal pain, swelling, or painless 

lumps/masses. 

▪ Answer “NO” if student does NOT have any testicular/scrotal pain, swelling or painless 

lumps/masses. 

▪ Fully explain any pain, swelling or painless lumps on or near the testicles and/or scrotum. Are your 

testicles the same size? Do they hurt? Include any other necessary details in the explanation box 

after question #21. 

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DISCLOSURE & CONSENT INFORMATION 


It is understood that even though protective equipment is worn by the athlete, whenever needed, 

the possibility of an accident still remains. Neither the University Interscholastic League nor the 

school assumes any responsibility in case an accident occurs. 

If, in the judgment of any representative of the school, the above student should need immediate 

care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent 

to such care and treatment as may be given said student by any physician, athletic trainer, nurse or 

school representative. I do hereby agree to indemnify and save harmless the school and any school 

or hospital representative from any claim by any person on account of such care and treatment of 

said student. 

If, between this date and the beginning of athletic competition, any illness or injury should occur that 

may limit this student's participation, I agree to notify the school authorities of such illness or injury. 

S T U D E N T S I G N AT U R E PA R E N T/ G U A R D I A N S I G N AT U R E D AT E 

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DISCLOSURE & CONSENT INFORMATION 


Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation 

which may include a physical examination. Written clearance from a physician, 

physician assistant, chiropractor, or nurse practitioner is required before any 

participation in UIL practices, games or matches. THIS FORM MUST BE ON FILE 

PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMAGE OR CONTEST BEFORE, 

DURING OR AFTER SCHOOL. 

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BACK PAGE 


ONLY complete the top line (Student’s Name, Sex, Age and Date of Birth) on the 

back page of the Medical History Form. Everything else below the top line will be 

filled out by the doctor during the actual physical evaluation. 

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GUIDE: How to Fill Out the UIL Pre-Participation Medical History Form

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