GUIDE: How to Fill Out the UIL Pre-Participation Medical History Form
Step-by-step guide for completing the UIL Pre-Participation Physical Evaluation Medical History Form.
Step-by-step guide for completing the UIL Pre-Participation Physical Evaluation Medical History Form.
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<strong>UIL</strong> PRE-PARTICIPATION PHYSICAL EVALUATION<br />
STEP-BY-STEP <strong>GUIDE</strong> TO COMPLETE THE MEDICAL HISTORY FORM
TABLE OF CONTENTS<br />
⃝ About Adolescent Sports Metrics<br />
⃝ Before You Begin…<br />
⃝ About <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong><br />
• Top Section Instructions<br />
• Instructions for Questionnaire<br />
• “YES” Answer Explanation Box<br />
• Question #1<br />
• Question #2<br />
• Question #3A<br />
• Question #3B • Question #3G<br />
• Question #3C • Question #3H<br />
• Question #3D • Question #3I<br />
• Question #3E • Question #3J<br />
• Question #3F • Question #3K<br />
• Question #4A<br />
• Question #4B<br />
• Question #4C<br />
• Question #4D<br />
• Question #4E<br />
• Question #4F<br />
• Question #5<br />
• Question #6<br />
• Question #7<br />
• Question #8<br />
• Question #9<br />
• Question #10<br />
• Question #11<br />
Question #12<br />
Question #13A<br />
• • Question #13B<br />
• • Question #13C<br />
• Question #14<br />
• Question #15A<br />
• Question #15B<br />
• Question #15C<br />
• Question #16<br />
• Question #17<br />
• Question #18<br />
⃝ Notes about Question #19<br />
• Question #19A (FEMALES ONLY)<br />
• Question #19B<br />
• Question #19C<br />
• Question #20 (MALES ONLY)<br />
• Question #21 (MALES ONLY)<br />
⃝ Disclosure & Consent Information<br />
⃝ Back Page - <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong><br />
©2019 Adolescent Sports Metrics 501(c)(3)
10 <strong>Medical</strong> Parkway | Plaza 3, Suite 201 | Farmers Branch, TX 75234 | (469) 657-5244<br />
Adolescent Sports Metrics (ASM) is a 501 (c)(3) nonprofit organization founded in 2017. ASM’s mission is <strong>to</strong> collect data from<br />
young athletes during <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Evaluations in order <strong>to</strong> establish what “normal” looks like in this demographic<br />
group. “Normal” data ranges are not currently available for various reasons, primarily because this age group does not see<br />
healthcare providers unless ill. As a result, <strong>the</strong> data collected during sick visits do not improve diagnoses for providers or<br />
outcomes for patients. By allowing ASM <strong>to</strong> serve your children, you allow us <strong>to</strong> serve everyone's in <strong>the</strong> future with better data,<br />
for better research and better futures.<br />
Website: www.AdolescentSportsMetrics.org Facebook: @ASMetrics Twitter: @ASportsMetrics<br />
©2019 Adolescent Sports Metrics 501(c)(3)
BEFORE YOU BEGIN…<br />
<strong>UIL</strong> PRE-PARTICIPATION EVALUATION - MEDICAL HISTORY FORM FACTS<br />
The information provided in this presentation is not in lieu of medical advice. This step-by-step guide was created <strong>to</strong> help Coaches,<br />
Parents/Guardians and Students complete <strong>the</strong> <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong>.<br />
The purpose of <strong>the</strong> <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical & <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong> is not <strong>to</strong> exclude a child from sport-related activities, but <strong>to</strong><br />
make participation safe and <strong>to</strong> alert <strong>the</strong> parent/guardian of any health care issues that may arise.<br />
▪<br />
▪<br />
▪<br />
Parent/Guardian should complete <strong>the</strong> <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong> with <strong>the</strong> child present. The child may be able <strong>to</strong> answer some of <strong>the</strong> questions or<br />
provide necessary information that <strong>the</strong> parent/guardian is not currently aware of or privy <strong>to</strong>.<br />
If a child has a chronic health care condition that is currently being treated by a physician, a school sponsored group physical is NOT <strong>the</strong> appropriate<br />
place for that child <strong>to</strong> obtain his/her <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical. The child should visit and obtain his/her physical from <strong>the</strong> treating physician. The<br />
treating physician’s written approval is required for <strong>the</strong> child’s participation in any sport-related activity.<br />
If you answer “YES” <strong>to</strong> question #5 on <strong>the</strong> <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong>, “Are you missing any paired organs?” (for example, a lung or kidney), a school<br />
sponsored group physical is NOT <strong>the</strong> appropriate place for your child <strong>to</strong> obtain his/her <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical. A Clearance Letter from a<br />
Specialist allowing <strong>the</strong> child <strong>to</strong> participate in a sport-related activity will be required.<br />
For those planning <strong>to</strong> visit a Primary Care Physician <strong>to</strong> obtain <strong>the</strong>ir child’s physical:<br />
1. The <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical Evaluation must be completed prior <strong>to</strong> tryouts for any school sponsored, sport-related activity.<br />
2. The physical must NOT be completed and dated prior <strong>to</strong> April 1 st . <strong>How</strong>ever, district rules can supersede that date, in which case, <strong>the</strong> date becomes<br />
May 1 st of <strong>the</strong> previous school year.<br />
3. <strong>UIL</strong> states on <strong>the</strong>ir forms and website that a Physical Evaluation is only needed every 2 years. <strong>How</strong>ever, district rules require an annual Physical<br />
Evaluation <strong>to</strong> participate in athletics, practices or games.<br />
4. If you plan <strong>to</strong> use your insurance and one annual wellness exam with child’s primary care physician <strong>to</strong> obtain child’s physical, please schedule your<br />
visit/physical during <strong>the</strong> first 2 weeks of May.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
ABOUT THE MEDICAL HISTORY FORM<br />
<strong>UIL</strong> PRE-PARTICIPATION EVALUATION<br />
MEDICAL HISTORY FORM<br />
must be completed annually<br />
by parent (or guardian) and<br />
student in order for <strong>the</strong><br />
student <strong>to</strong> participate in<br />
athletic activities. These<br />
questions are designed <strong>to</strong><br />
determine if <strong>the</strong> student has<br />
developed any condition<br />
which would make it<br />
hazardous <strong>to</strong> participate in an<br />
athletic event.<br />
Click <strong>the</strong> red icon <strong>to</strong><br />
download <strong>the</strong> form or<br />
visit <strong>the</strong> <strong>UIL</strong> website.<br />
PAGE 1 PAGE 2<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
TOP SECTION INSTRUCTIONS<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
▪ Student’s parent or guardian should fill out <strong>the</strong> <strong>to</strong>p section of <strong>the</strong> form and print legibly. If<br />
a student requires a referral and <strong>the</strong> information in this section cannot be read, <strong>the</strong><br />
student’s referral and <strong>the</strong>refore, eligibility <strong>to</strong> participate in athletic activities, may be<br />
delayed.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
INSTRUCTIONS FOR QUESTIONNAIRE<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
Explain “Yes” answers in <strong>the</strong> box below**. Circle questions you<br />
don’t know <strong>the</strong> answers <strong>to</strong>.<br />
▪ ALL “Yes” answers must be fully explained (with necessary details – date or age of occurrence,<br />
situation explanation, family medical his<strong>to</strong>ry, etc.) in <strong>the</strong> box under <strong>the</strong> last question, #21. Attach<br />
ano<strong>the</strong>r piece of paper <strong>to</strong> <strong>the</strong> <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong> if more space is needed <strong>to</strong> explain any “Yes”<br />
answers for questions #1 - #21.<br />
▪ Circle all questions <strong>the</strong> student or parent/guardian cannot answer.<br />
▪ If a student is adopted and his<strong>to</strong>ry is unknown please answer all questions <strong>to</strong> <strong>the</strong> best of your<br />
ability. Then state in <strong>the</strong> explanation box <strong>the</strong> student is adopted and family his<strong>to</strong>ry is unknown.<br />
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“YES”<br />
ANSWERS<br />
EXPLANATION<br />
BOX<br />
Box for fur<strong>the</strong>r explanation of any<br />
and all “Yes” answers located at<br />
bot<strong>to</strong>m of page 1 on <strong>the</strong> <strong>Medical</strong><br />
His<strong>to</strong>ry <strong>Form</strong> under question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #1<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
1. Have you had a medical illness or injury since your last check<br />
up or sports physical?<br />
▪ Answer “YES” if student has had any type of medical illness or injury in <strong>the</strong> past 12<br />
months (since last annual <strong>UIL</strong> physical or 1 year prior <strong>to</strong> date of current <strong>UIL</strong> physical).<br />
▪ Which was it: Illness or Injury? Circle one or both if appropriate and fully explain.<br />
▪ “<strong>Medical</strong> illness or injury” refers <strong>to</strong> any form of sickness or physical injury severe enough <strong>to</strong> require<br />
hospitalization or continued treatment by a healthcare provider (e.g.,<br />
▪ Broken bone(s)<br />
▪ Surgery of any kind<br />
▪ Communicable Diseases (Measles, Hepatitis, STDs, HIV/AIDS, Tetanus, etc.)<br />
▪ Recent diagnoses (asthma, congenital conditions, etc.)<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> illness or injury, duration, recommended treatment, and include<br />
any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #2<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
2. Have you been hospitalized overnight in <strong>the</strong> past year?<br />
Have you ever had surgery?<br />
▪ TOP QUESTION: Answer “YES” if student has had <strong>to</strong> spend a night in <strong>the</strong> hospital for any reason<br />
over <strong>the</strong> past year (since last annual <strong>UIL</strong> physical or 1 year prior <strong>to</strong> date of current <strong>UIL</strong> physical).<br />
▪ Fully explain <strong>the</strong> situation and any necessary details of <strong>the</strong> overnight hospital stay in <strong>the</strong> explanation box after<br />
question #21.<br />
▪ BOTTOM QUESTION: Answer “YES” if student has had a surgery of any kind at any point in <strong>the</strong>ir<br />
lifetime.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> surgery and why it was necessary. Include any o<strong>the</strong>r necessary<br />
details of <strong>the</strong> surgery in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3A<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you ever had prior testing for <strong>the</strong> heart ordered by a<br />
physician?<br />
▪ Answer “YES” if student has had one or more heart tests ordered (even if testing wasn’t actually<br />
performed) by a physician at any point in <strong>the</strong>ir lifetime.<br />
▪ Heart Tests Include: Angiography, Blood <strong>Pre</strong>ssure Moni<strong>to</strong>ring, Blood Tests, Echocardiogram (echo),<br />
Electrocardiograph (ECG), Electrophysiological Studies, Myocardial Perfusion Scans & Tilt Table Test.<br />
▪ If you’ve had surgery, <strong>the</strong>n you’ve had heart moni<strong>to</strong>ring while in <strong>the</strong> hospital for surgery. Heart<br />
moni<strong>to</strong>ring is NOT heart testing. The question is: Has any doc<strong>to</strong>r ordered tests specifically on<br />
your heart?<br />
▪ If “YES”, fully explain why heart tests were ordered, what <strong>the</strong> results were and include any o<strong>the</strong>r<br />
necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #3B<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you ever passed out during or after exercise?<br />
▪ Answer “YES” if student has ever fainted/passed out (even if only for a few seconds)<br />
during or immediately after exercise at any point in <strong>the</strong>ir lifetime.<br />
▪ Which was it: During or After? Circle one or both if appropriate and fully explain.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> fainting episode. What type of exercise? Did you seek<br />
medical attention? What was <strong>the</strong> outcome? <strong>How</strong> often do you pass out with exercise? Include<br />
any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3C<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you ever had chest pain during or after exercise?<br />
▪ Answer “YES” if student has ever had obvious chest pains during or immediately after<br />
exercise at any point in <strong>the</strong>ir lifetime.<br />
▪ Which was it: During or After exercise? Circle one or both if appropriate and fully<br />
explain.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> chest pains episode(s). What type of exercise? Did you<br />
seek medical attention? What was <strong>the</strong> outcome? <strong>How</strong> often do you have chest pain with<br />
exercise? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3D<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Do you get tired more quickly than your friends do during<br />
exercise?<br />
▪ Answer “YES” if student has trouble keeping up with <strong>the</strong> physical performance level of<br />
o<strong>the</strong>r kids his/her age including more severe than expected shortness of breath,<br />
coughing or wheezing symp<strong>to</strong>ms during exercise.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> student’s inability <strong>to</strong> maintain an average physical<br />
performance level comparative <strong>to</strong> peers. What type of exercise? <strong>How</strong> often does this occur?<br />
Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #3E<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you ever had racing of your heart or skipped<br />
heartbeats?<br />
▪ Answer “YES” if student has ever had heart palpitations (skipping beats, fluttering<br />
rapidly, beating <strong>to</strong>o fast, pounding or flip-flopping) felt in <strong>the</strong> throat, neck or chest at<br />
any point in <strong>the</strong>ir lifetime.<br />
▪ Fully explain <strong>the</strong> situation/environment leading up <strong>to</strong> and during <strong>the</strong> heart palpitations. Did you<br />
seek medical care for <strong>the</strong> palpitations? If so, when & where did you seek medical attention?<br />
What was <strong>the</strong> outcome? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question<br />
#21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #3F<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you had high blood pressure or high cholesterol ?<br />
▪ Answer “YES” if student has ever been diagnosed with high blood pressure or high<br />
cholesterol by a healthcare provider at any point in <strong>the</strong>ir lifetime.<br />
▪ Which was it: High Blood <strong>Pre</strong>ssure or High Cholesterol? Circle one or both if<br />
appropriate and fully explain.<br />
▪ Fully explain <strong>the</strong> situation/environment leading up <strong>to</strong> and during <strong>the</strong> diagnosis. Were you<br />
medicated? Have you been released? Include any o<strong>the</strong>r necessary details (such as doc<strong>to</strong>r<br />
recommendations for treating condition) in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3G<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you ever been <strong>to</strong>ld you have a heart murmur?<br />
▪ Answer “YES” if student has ever been diagnosed with a heart murmur by a healthcare<br />
provider at any point in <strong>the</strong>ir lifetime.<br />
▪ A Heart Murmur is an unusual sound heard between heartbeats. Murmurs sometimes sound like a<br />
whooshing or swishing noise.<br />
▪ Fully explain <strong>the</strong> situation/environment leading up <strong>to</strong> and during <strong>the</strong> heart murmur diagnosis.<br />
When was it diagnosed? When was <strong>the</strong> last time you were seen for it? If you have been cleared,<br />
you MUST provide that clearance documentation. Include any o<strong>the</strong>r necessary details in <strong>the</strong><br />
explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #3H<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Has any family member or relative died of heart problems or<br />
of sudden unexpected death before age 50?<br />
▪ Answer “YES” if student knows he or she has a family his<strong>to</strong>ry (any blood relative) of<br />
heart problems and sudden unexpected death.<br />
▪ Fully explain <strong>the</strong> situation (when <strong>the</strong> parent/student learned <strong>the</strong> family his<strong>to</strong>ry information and<br />
who provided that information). Which side of <strong>the</strong> family has <strong>the</strong> his<strong>to</strong>ry of heart problems<br />
(mo<strong>the</strong>r’s or fa<strong>the</strong>r’s side)? Was it your mo<strong>the</strong>r/fa<strong>the</strong>r that had <strong>the</strong> heart problem? Include any<br />
o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3I<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Has any family member been diagnosed with enlarged heart<br />
(dilated cardiomyopathy), hypertrophic cardiomyopathy, long QT<br />
syndrome or o<strong>the</strong>r ion channelopathy (Brugada syndrome, etc.)<br />
Marfan’s syndrome, or abnormal heart rhythm?<br />
▪ Answer “YES” if student knows he or she has a family his<strong>to</strong>ry of any of <strong>the</strong> following:<br />
▪ Enlarged Heart – heart’s ability <strong>to</strong> pump blood decreased because left ventricle enlarged & weakened.<br />
▪ Hypertrophic Cardiomyopathy – disease in which heart muscle becomes abnormally thick.<br />
▪ Long QT Syndrome (LQTS) – condition affecting repolarization of heart after heartbeat. Higher risk of irregular heartbeat possibly<br />
resulting in palpitations, fainting, drowning or sudden death.<br />
▪ Ion Channelopathies – diseases caused by disturbed function of ion channel<br />
▪ Brugada Syndrome – heart rhythm disorder that is sometimes inherited.<br />
▪ Marfan Syndrome – genetic disorder affecting body’s connective tissue (often in heart)<br />
▪ Abnormal Heart Rhythm – heart rate <strong>to</strong>o fast, <strong>to</strong>o slow or irregular.<br />
▪ Fully explain <strong>the</strong> situation (when <strong>the</strong> parent/student learned <strong>the</strong> family his<strong>to</strong>ry information and who<br />
provided that information). Who was <strong>the</strong> family member diagnosed? Include any o<strong>the</strong>r necessary<br />
details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #3J<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Have you had a severe viral infection (for example,<br />
myocarditis or mononucleosis) within <strong>the</strong> last month?<br />
▪ Answer “YES” if student was diagnosed with severe viral infection within last 30 days.<br />
▪ Myocarditis – inflammation of <strong>the</strong> heart muscle that can affect heart muscle & heart’s electrical<br />
system reducing its ability <strong>to</strong> pump and causing rapid or abnormal heart rhythms (arrhythmias).<br />
▪ Mononucleosis (mono or “<strong>the</strong> kissing disease”) - infectious illness spread through bodily fluids,<br />
usually mild fatigue symp<strong>to</strong>ms but can lead <strong>to</strong> complications that can make it more dangerous.<br />
▪ Fully explain <strong>the</strong> situation surrounding diagnosis and include any o<strong>the</strong>r necessary details (such as<br />
severity, complications, etc.) in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #3K<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
3. Has a physician ever denied or restricted your participation<br />
in sports for any heart problems?<br />
▪ Answer “YES” if student has ever been <strong>to</strong>ld <strong>to</strong> avoid sport activities by a physician for<br />
any type of heart related problem(s) at any point in <strong>the</strong>ir lifetime.<br />
▪ Fully explain <strong>the</strong> situation, <strong>the</strong> type of heart problem(s) diagnosed and reason for restricted<br />
physical activity. Provide <strong>the</strong> treating doc<strong>to</strong>r’s documented release <strong>to</strong> participate in sports.<br />
Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #4A<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Have you ever had a head injury or concussion?<br />
▪ Answer “YES” if student has ever had a concussion (injury <strong>to</strong> <strong>the</strong> brain resulting in<br />
temporary loss of normal brain function) or injured <strong>the</strong>ir head in any way at any point<br />
in <strong>the</strong>ir lifetime.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> injury and any symp<strong>to</strong>ms experienced. Were you<br />
treated by a medical provider? If so, what was <strong>the</strong> diagnosis and/or recommended treatment?<br />
Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #4B<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Have you ever been knocked out, become unconscious, or lost your memory?<br />
If yes, how many times?<br />
fill in blank<br />
When was your last concussion?<br />
fill in blank<br />
<strong>How</strong> severe was each one? (Explain below)<br />
▪ Answer “YES” if student has ever experienced a knock-out blow (a concussion or traumatic brain injury) or loss of<br />
memory, even for a few seconds, after injuring <strong>the</strong>ir head in any way at any point in <strong>the</strong>ir lifetime.<br />
▪<br />
▪ If “YES”, fill in <strong>the</strong> blank with <strong>the</strong> number of times <strong>the</strong> student has experienced a knock-out blow and/or memory loss.<br />
▪ <strong>Fill</strong> in <strong>the</strong> blank with <strong>the</strong> full date (mm/dd/yyyy) of student’s last concussion.<br />
▪ <strong>How</strong> severe was each concussion experienced by student? Answer <strong>the</strong> following questions for each concussion<br />
experienced in <strong>the</strong> Explanation Box below question #21: Length of time student was unconscious? Was internal<br />
bleeding or swelling present? Any noticeable & lasting behavioral or cognitive changes? <strong>How</strong> long was student out for<br />
recovery?<br />
Fully explain <strong>the</strong> situation surrounding <strong>the</strong> knock-out blow/injury, any symp<strong>to</strong>ms experienced, length of time student<br />
was unconscious, length of time student was out for recovery, diagnosis and/or recommended treatment, number of<br />
knock-out blows experienced, date of last concussion and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box<br />
after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #4C<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Have you ever had a seizure?<br />
▪ Answer “YES” if student has ever experienced a sudden, uncontrolled electrical<br />
disturbance in <strong>the</strong> brain causing changes in behavior, movements or feeling & in levels<br />
of consciousness at any point in <strong>the</strong>ir lifetime.<br />
▪ If student has had anything o<strong>the</strong>r than a febrile seizure (convulsion caused by a fever or<br />
spike in body temperature) as an infant/<strong>to</strong>ddler, a release from <strong>the</strong> treating<br />
neurologist will be required for student <strong>to</strong> participate in sports.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> seizure, any symp<strong>to</strong>ms experienced, length of time<br />
seizure lasted, diagnosis and/or recommended treatment, and include any o<strong>the</strong>r necessary details<br />
in <strong>the</strong> explanation box after question #21.<br />
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QUESTION #4D<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Do you have frequent or severe headaches?<br />
▪ Answer “YES” if student is currently experiencing headaches of any kind due <strong>to</strong> a recent<br />
concussion.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> headaches. If you are female: Do <strong>the</strong> headaches occur<br />
around your menstrual cycle? Do you drink enough water? Do you eat healthy foods? Do you<br />
wear glasses? <strong>How</strong> often do <strong>the</strong> headaches occur (1 per month, 1 per week, etc.)? Describe<br />
“severe” on a scale of 1 <strong>to</strong> 10 (1 being low pain and 10 being extreme pain). Is medication<br />
needed? If so, what medication do you take <strong>to</strong> manage <strong>the</strong> pain/headaches? Include <strong>the</strong> length<br />
of time <strong>the</strong> headaches typically last, diagnosis and/or recommended treatment, and any o<strong>the</strong>r<br />
necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #4E<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Have you ever had numbness or tingling in your arms, hands,<br />
legs or feet?<br />
▪ This question is NOT asking if your hands or feet fall asleep when you sit on <strong>the</strong>m for an<br />
extended period of time. It IS asking if your hands or feet randomly feel tingly and/or<br />
funny while you are using <strong>the</strong>m (running, walking, writing, carrying something, etc.).<br />
▪ Answer “YES” if student has ever experienced a tingling sensation or numbness in <strong>the</strong>ir<br />
arms, hands, legs or feet at any point in <strong>the</strong>ir lifetime after a concussion or head<br />
injury.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> tingling or numbness sensations, which extremities<br />
affected, length of time sensations typically lasted, severity of tingling or numbness on a scale of 1<br />
<strong>to</strong> 10 (1 being low pain and 10 being extreme pain), diagnosis and/or recommended treatment,<br />
and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #4F<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
4. Have you ever had a stinger, burner, or pinched nerve?<br />
▪ If you don’t know what <strong>the</strong>se are, answer “NO” because you have never had one.<br />
▪ Answer “YES” if student has ever experienced a burner, stinger or pinched nerve at any<br />
point in <strong>the</strong>ir lifetime after a concussion or head injury.<br />
▪ Burners & Stingers are injuries that occur when nerves in <strong>the</strong> neck and shoulders are stretched or compressed after and<br />
impact. They can feel like an electric shock or lightning bolt down <strong>the</strong> arm.<br />
▪ A pinched nerve occurs when <strong>to</strong>o much pressure is applied <strong>to</strong> a nerve by surrounding tissue, such as bones, cartilage,<br />
muscles or tendons. The pressure disrupts <strong>the</strong> nerve’s function causing pain, tingling, numbness or weakness.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> pain/sensations experienced, describe <strong>the</strong> pain/sensation<br />
(burning, stinging, weakness, etc.), length of time sensations typically lasted, severity of sensations on a<br />
scale of 1 <strong>to</strong> 10 (1 being low pain and 10 being extreme pain), diagnosis and/or recommended<br />
treatment, and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #5<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
5. Are you missing any paired organs?<br />
▪ Answer “YES” if student is missing or has had any paired organs surgically removed at any point<br />
in <strong>the</strong>ir lifetime.<br />
▪ Paired organs include: ears, eyes, lungs, kidneys, ovaries, or testes.<br />
▪ If answer is “YES,” <strong>the</strong>n a school sponsored group physical is NOT <strong>the</strong> appropriate place for <strong>the</strong><br />
student <strong>to</strong> obtain his/her <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical. The <strong>UIL</strong> is very clear about missing<br />
paired organs such as a kidney or lung. You must have Pulmonary (lung doc<strong>to</strong>r) or Nephrology<br />
(kidney doc<strong>to</strong>r) clearance <strong>to</strong> participate in a sport-related activity.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> missing and/or removed organ, describe any related<br />
illness, injury or birth defect resulting in <strong>the</strong> missing organ, diagnosis and/or recommended<br />
treatment and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #6<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
6. Are you under a doc<strong>to</strong>r’s care?<br />
▪ This question is NOT asking if <strong>the</strong> student has a doc<strong>to</strong>r.<br />
▪ Answer “YES” if student is currently being treated by a physician for a medical<br />
condition (illness, injury, etc.). Only answer “YES” if student is in <strong>the</strong> middle of receiving<br />
treatment for a medical condition from a doc<strong>to</strong>r.<br />
▪ If student answers “YES”, <strong>the</strong>n a school sponsored group physical is NOT <strong>the</strong> appropriate<br />
place for <strong>the</strong> student <strong>to</strong> obtain his/her <strong>UIL</strong> <strong>Pre</strong>-<strong>Participation</strong> Physical. When <strong>the</strong><br />
treatment/care has been completed, <strong>the</strong>n <strong>the</strong> student can get a physical.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> medical condition (illness, injury, etc.) currently being treated,<br />
describe <strong>the</strong> diagnosis and/or recommended treatment, length of time affected by medical condition<br />
and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #7<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
7. Are you currently taking any prescription or non-prescription<br />
(over-<strong>the</strong>-counter) medication or pills or using and inhaler?<br />
▪ Answer “YES” if student is currently taking any prescription or non-prescription<br />
medication or pills (such as pain relievers, allergy or cold/cough medicines, sleeping<br />
pills, anti-depressants, stimulants like Adderall or vitamins) or regularly using an inhaler<br />
for treatment of asthma.<br />
▪ Which is it: <strong>Pre</strong>scription or Non-<strong>Pre</strong>scription? Circle one or both if appropriate and fully explain.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> medical condition (illness, injury, allergy, depression, asthma, etc.)<br />
<strong>the</strong> student or primary care physician is treating with prescription or OTC pills and/or an inhaler. What<br />
medication(s) are you taking? Why are you taking <strong>the</strong> medication(s)? What is <strong>the</strong> dosage? Describe <strong>the</strong><br />
diagnosis and/or recommended treatment, length of time affected by medical condition and include any<br />
o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #8<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
8. Do you have any allergies (for example, <strong>to</strong> pollen, medicine,<br />
food, or stinging insects)?<br />
▪ Answer “YES” if student has any known allergies <strong>to</strong> pollen (seasonal), any type of food,<br />
any medicines or stinging insects (bees, wasps, or ants).<br />
▪ Fully explain <strong>the</strong> allergy (what causes <strong>the</strong> allergic reaction), <strong>the</strong> severity of <strong>the</strong> reaction and<br />
recommended treatment. Do you have an EpiPen? Include any o<strong>the</strong>r necessary details in <strong>the</strong><br />
explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #9<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
9. Have you ever been dizzy during or after exercise?<br />
▪ Answer “YES” if student has ever consistently felt dizzy during or after exercise<br />
(especially light exercise) at any point in <strong>the</strong>ir lifetime. Consistent light-headedness or<br />
dizziness during or immediately after even light exercise could be caused by an<br />
underlying heart problem.<br />
▪ Which is it: During or After? Circle one or both if appropriate and fully explain.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> dizziness spell(s). What type of exercise? Was student<br />
hydrated and had <strong>the</strong>y eaten that day? Describe <strong>the</strong> diagnosis and/or recommended treatment,<br />
number of times <strong>the</strong> student has experienced dizziness during or after exercise, severity of<br />
symp<strong>to</strong>ms and include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #10<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
10. Do you have any current skin problems (for example,<br />
itching rashes, acne, warts, fungus, or blisters)?<br />
▪ Answer “YES” if student currently has any severe or unusual skin conditions.<br />
▪ Some skin conditions are contagious (STDs, fungal infections, etc.). Severe acne might<br />
be treated with medications (such as Accutane) that can cause noticeable side effects<br />
that may explain o<strong>the</strong>r issues or conditions. Certain skin problems can signal a heart<br />
problem as well.<br />
▪ Fully explain <strong>the</strong> situation surrounding any skin conditions student is currently suffering from, how<br />
long student has had <strong>the</strong> skin condition and whe<strong>the</strong>r or not student is being treated by a doc<strong>to</strong>r or<br />
is taking medications <strong>to</strong> treat <strong>the</strong> skin condition. Include any o<strong>the</strong>r necessary details in <strong>the</strong><br />
explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #11<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
11. Have you ever become ill from exercising in <strong>the</strong> heat?<br />
▪ Answer “YES” if student has ever gotten sick (weakness, vomiting, muscle cramps,<br />
headache, heavy sweating, dizziness, etc.) while exercising in <strong>the</strong> heat.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> heat sickness. What type of symp<strong>to</strong>ms did you<br />
experience? <strong>How</strong> hot was it that day? What did you eat and/or drink that day? If you sought<br />
medical care, what was <strong>the</strong> diagnosis and/or recommended treatment? <strong>How</strong> many times have<br />
you experienced heat sickness? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after<br />
question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #12<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
12. Have you had any problems with your vision or eyes?<br />
▪ Answer “YES” if student has ever had vision problems (sudden or recurrent eye pain,<br />
hazy, blurred or double vision, flashes of light, rainbows or halos around lights, etc.) at<br />
any point in <strong>the</strong>ir lifetime.<br />
▪ Nearsightedness – objects up close appear clearly while objects far away appear blurry<br />
▪ Farsightedness – distant objects may be seen more clearly than objects that are near<br />
▪ Astigmatism – images appear blurry and stretched out<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> vision or eye problem(s). Have you been <strong>to</strong> an<br />
Op<strong>to</strong>metrist or Ophthalmologist (eye doc<strong>to</strong>r)? What was <strong>the</strong> diagnosis or recommended<br />
treatment? Have you been prescribed eye glasses or contacts? Include any o<strong>the</strong>r necessary<br />
details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #13A<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
13. Have you ever gotten unexpectedly short of breath with<br />
exercise?<br />
▪ Answer “YES” if student has ever experienced exercise-induced shortness of breath at<br />
any point in <strong>the</strong>ir lifetime.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> shortness of breath. What type of exercise? <strong>How</strong> long<br />
had you been exercising? Did you seek medical care? If so, what was <strong>the</strong> diagnosis or outcome?<br />
Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #13B<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
13. Do you have asthma?<br />
▪ Answer “YES” if student has been diagnosed by a health care provider with asthma.<br />
▪ Asthma – A chronic disease causing <strong>the</strong> airways (bronchial tubes) in <strong>the</strong> lungs <strong>to</strong> become inflamed and swollen.<br />
The muscles around <strong>the</strong> airways can tighten when something triggers your symp<strong>to</strong>ms.<br />
▪ Fully explain <strong>the</strong> situation surrounding an asthma attack. <strong>How</strong> often do your asthma attacks<br />
occur? <strong>How</strong> long do <strong>the</strong> attacks usually last? Do you have or regularly use a rescue inhaler? If<br />
you do NOT have an inhaler, when was your last asthma attack? Include any o<strong>the</strong>r necessary<br />
details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #13C<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
13. Do you have seasonal allergies that require medical<br />
treatment?<br />
▪ Answer “YES” if student has allergies that require medical treatment (prescription or<br />
non-prescription antihistamines, decongestants, nasal spray, etc.).<br />
▪ Fully explain <strong>the</strong> situation surrounding need for medical treatment of seasonal allergies. What<br />
type of medical treatment do you take/use? Was it prescribed or is it over-<strong>the</strong>-counter? <strong>How</strong><br />
often do you take <strong>the</strong> medicine <strong>to</strong> treat your allergies? Include any o<strong>the</strong>r necessary details in <strong>the</strong><br />
explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #14<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
14. Do you use any special protective or corrective equipment or devices that<br />
aren’t usually used for your sport or position (for example, knee brace,<br />
special neck roll, foot orthotics, retainer on your teeth, hearing aid)?<br />
▪ Answer “YES” if student regularly wears protective or corrective equipment while<br />
playing sports.<br />
▪ Fully explain <strong>the</strong> situation and/or need <strong>to</strong> use <strong>the</strong> equipment or devices. What equipment do you<br />
use? Is it used <strong>to</strong> protect or correct? <strong>How</strong> long have you used <strong>the</strong> equipment? Include any o<strong>the</strong>r<br />
necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #15A<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
15. Have you ever had a sprain, strain, or swelling after injury?<br />
▪ Answer “YES” if student has ever had a severe sprain, strain or swelling after an injury.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> injury. Did you seek medical care (this includes your<br />
school’s Athletic Trainer)? Did you follow and complete care/rehabilitation? <strong>How</strong> long were you<br />
out for recovery? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #15B<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
15. Have you broken or fractured any bones or dislocated any<br />
joints?<br />
▪ Answer “YES” if student has ever fractured (broken) any bones or dislocated (injured)<br />
any joints at any point in <strong>the</strong>ir lifetime.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> broken bone(s) or dislocated joint(s). What bone did<br />
you break or joint did you dislocate? <strong>How</strong> severe was <strong>the</strong> break or joint injury? <strong>How</strong> long were<br />
you out for recovery? Did you follow and complete care/rehabilitation? Include any o<strong>the</strong>r<br />
necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #15C<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
15. Have you had any o<strong>the</strong>r problems with pain or swelling in muscles, tendons,<br />
bones or joints?<br />
If yes, check appropriate box and explain below:<br />
Head Elbow Hip<br />
Neck Forearm Thigh<br />
Back Wrist Knee<br />
Chest Hand Shin/Calf<br />
Shoulder Finger Ankle<br />
Upper Arm<br />
Foot<br />
▪<br />
▪<br />
▪<br />
Answer “YES” if student has ever had recurrent problems with pain or swelling in any muscles, tendons, bones or joints<br />
at any point in <strong>the</strong>ir lifetime.<br />
Check all <strong>the</strong> boxes that apply <strong>to</strong> <strong>the</strong> areas <strong>the</strong> student has experienced recurring pain or swelling in.<br />
Please circle one or both if appropriate and fully explain: Pain or Swelling? AND Muscles, Tendons, Bones or Joints?<br />
▪<br />
Fully explain <strong>the</strong> situation surrounding <strong>the</strong> pain or swelling in each box marked. <strong>How</strong> long have you had problems in <strong>the</strong> areas<br />
marked? <strong>How</strong> severe was <strong>the</strong> pain or swelling? Did you seek medical care? If so, what was <strong>the</strong> diagnosis and recommended<br />
treatment? Did you follow and complete care/rehabilitation? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after<br />
question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #16<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
16. Do you want <strong>to</strong> weigh more or less than you do now?<br />
▪ Answer “YES” if student would like <strong>to</strong> lose weight or put on more weight.<br />
▪ Which is it: More or Less? Please circle and fully explain.<br />
▪ Fully explain. Why do you want <strong>to</strong> weight more or less than you currently do? Include any o<strong>the</strong>r<br />
necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #17<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
17. Do you feel stressed out?<br />
▪ Answer “YES” if student is feeling stressed or currently under a lot of pressure for any<br />
reason (home life, academics, social, extracurricular actives or sport teams, etc.).<br />
▪ Fully explain <strong>the</strong> situation(s) surrounding or causing <strong>the</strong> stress. Why are you feeling stressed out?<br />
Do you know what specifically is causing most of your stress (home life/personal reasons,<br />
death in <strong>the</strong> family, school, friends, extracurricular activities like sport teams, etc.)? Have you<br />
sought counseling or medical care? Are you taking any medications <strong>to</strong> manage your stress?<br />
Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #18<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
18. Have you ever been diagnosed with or treated for sickle cell<br />
trait or sickle cell disease?<br />
▪ Answer “YES” if student has ever been tested for or diagnosed with sickle cell trait or<br />
sickle cell disease at any point in <strong>the</strong>ir lifetime.<br />
▪ Sickle Cell Trait (SCT) – is NOT a disease. Having SCT means that you have inherited <strong>the</strong> sickle cell gene from one of your<br />
parents. There are usually no symp<strong>to</strong>ms of sickle cell disease (SCD).<br />
▪ Sickle Cell Disease (SCD) – is a group of inherited red blood cell disorders. Your body may have trouble making enough<br />
new red blood cells <strong>to</strong> replaced damaged cells leading <strong>to</strong> a condition called anemia, which can make you feel tired.<br />
▪ Fully explain <strong>the</strong> situation surrounding <strong>the</strong> testing, diagnosis or treatment for sickle cell trait (SCT) or<br />
disease (SCD). Have you been tested? If so, when? What were <strong>the</strong> results of testing? If you were<br />
diagnosed with SCD, did you or are you currently receiving treatment? Include any o<strong>the</strong>r necessary<br />
details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
NOTES FOR FEMALE ONLY QUESTIONS (#19)<br />
<strong>UIL</strong> PREPARTICIPATION EVALUATION - MEDICAL HISTORY FORM<br />
▪ It may be helpful for female students <strong>to</strong> regularly track of <strong>the</strong>ir monthly<br />
menstrual cycles by marking <strong>the</strong> First Day of each cycle (<strong>the</strong> first day of period<br />
bleeding) on a calendar. This will allow students <strong>to</strong> count from <strong>the</strong> beginning of<br />
one menstrual period <strong>to</strong> <strong>the</strong> next <strong>to</strong> figure out <strong>the</strong>ir cycle lengths. This will also<br />
allow students <strong>to</strong> plan ahead and know about what time every month <strong>to</strong> expect<br />
<strong>the</strong>ir menstrual periods <strong>to</strong> begin.<br />
▪ For most women, <strong>the</strong> average menstrual cycle is 28 days, though it can range from<br />
21 <strong>to</strong> 35 days in adult women and still be considered normal.<br />
▪ In <strong>the</strong> first year, most girls have at least 4 periods; <strong>the</strong> second year, at least 6<br />
periods; and for <strong>the</strong> 3-5th year, at least 8 periods. Most adult women have 9 <strong>to</strong> 12<br />
periods a year. Your period will usually last between 3 and 7 days.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #19A (FEMALES ONLY)<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
19. When was your first menstrual period? fill in blank<br />
When was your most recent menstrual period?<br />
fill in blank<br />
▪ TOP QUESTION: Please fill in <strong>the</strong> blank with <strong>the</strong> date (mm/yyyy) of your first menstrual<br />
period ever. If you have not had your first menstrual period yet, please write N/A in <strong>the</strong><br />
blank.<br />
▪ BOTTOM QUESTION: Please fill in <strong>the</strong> blank with <strong>the</strong> date (mm/dd/yyyy) of <strong>the</strong> first<br />
day of your most recent menstrual period (NOT <strong>the</strong> day it ended). If you do not know<br />
<strong>the</strong> date, please write unknown in <strong>the</strong> blank.<br />
▪ Menstruation — aka having your period — is when blood and tissue from your uterus comes out of<br />
your vagina. It usually happens every month.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #19B (FEMALES ONLY)<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
19. <strong>How</strong> much time do you usually have from <strong>the</strong> start of one<br />
period <strong>to</strong> <strong>the</strong> start of ano<strong>the</strong>r?<br />
fill in blank<br />
▪ Please fill in <strong>the</strong> blank with <strong>the</strong> average number of days between <strong>the</strong> first day of your menstrual<br />
period (NOT <strong>the</strong> day it ends – aka s<strong>to</strong>p bleeding) <strong>to</strong> <strong>the</strong> last day before your next menstrual<br />
period begins (you start bleeding again). If you do not know, please write unknown in <strong>the</strong> blank.<br />
▪ To figure out how long your cycle is, start at cycle day 1 of your last menstrual cycle (first day<br />
you started bleeding) and begin counting (Cycle day 1, 2, 3, 4 and so forth). The Length =<br />
number of days from cycle day 1 <strong>to</strong> <strong>the</strong> last cycle day before you started bleeding again.<br />
▪ 28 days is an average number, but anywhere between 21 and 35 days is normal. In <strong>the</strong> first year, most girls have at least 4<br />
periods; <strong>the</strong> second year, at least 6 periods; and for <strong>the</strong> 3-5th year, at least 8 periods. Most adult women have 9 <strong>to</strong> 12<br />
periods a year. Your period will usually last between 3 and 7 days.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #19C (FEMALES ONLY)<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
19. <strong>How</strong> many periods have you had in <strong>the</strong> last year? fill in blank<br />
What was <strong>the</strong> longest time between periods in <strong>the</strong> last year?<br />
fill in blank<br />
▪ TOP QUESTION: Count <strong>the</strong> number of times you have had a menstrual period (bled) over <strong>the</strong><br />
last 12 months and fill in <strong>the</strong> blank with that number. If you do not know, please write unknown<br />
in <strong>the</strong> blank.<br />
▪ In <strong>the</strong> first year, most girls have at least 4 periods; <strong>the</strong> second year, at least 6 periods; and for <strong>the</strong> 3-5th year, at least 8<br />
periods. Most adult women have 9 <strong>to</strong> 12 periods a year. Your period will usually last between 3 and 7 days.<br />
▪ BOTTOM QUESTION: <strong>Fill</strong> in <strong>the</strong> blank with <strong>the</strong> longest number of days between periods (first<br />
day of your last cycle <strong>to</strong> <strong>the</strong> first day of your <strong>the</strong> next cycle) that you experienced in <strong>the</strong> last 12<br />
months. If you do not know, please write unknown in <strong>the</strong> blank.<br />
▪<br />
The menstrual cycle, which is counted from <strong>the</strong> first day of one period <strong>to</strong> <strong>the</strong> first day of <strong>the</strong> next, isn't <strong>the</strong> same for every<br />
woman. Menstrual flow might occur every 21 <strong>to</strong> 35 days and last two <strong>to</strong> seven days. For <strong>the</strong> first few years after<br />
menstruation begins, long cycles are common.<br />
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QUESTION #20 (MALES ONLY)<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
20. Do you have two testicles?<br />
▪ Answer “YES” if student has 2 testicles (balls).<br />
▪ Answer “NO” if student does NOT have 2 testicles (balls).<br />
▪ The testicles are two small, oval-shaped organs, contained in a sac of skin called <strong>the</strong> scrotum. They<br />
hang below <strong>the</strong> penis. The testicles are sometimes called <strong>the</strong> testes. They are <strong>the</strong> main organs of <strong>the</strong><br />
male reproductive system.<br />
▪ If answer is “NO”, how many testicles (balls) do you have? Why do you not have 2 testicles<br />
(balls)? Fully explain <strong>the</strong> situation surrounding <strong>the</strong> missing testicle. Include any o<strong>the</strong>r necessary<br />
details in <strong>the</strong> explanation box after question #21.<br />
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©2019 Adolescent Sports Metrics 501(c)(3)
QUESTION #21 (MALES ONLY)<br />
<strong>UIL</strong> PPE – MEDICAL HISTORY FORM<br />
21. Do you have any testicular swelling or masses?<br />
▪ Answer “YES” if student has any testicular/scrotal pain, swelling, or painless<br />
lumps/masses.<br />
▪ Answer “NO” if student does NOT have any testicular/scrotal pain, swelling or painless<br />
lumps/masses.<br />
▪ Fully explain any pain, swelling or painless lumps on or near <strong>the</strong> testicles and/or scrotum. Are your<br />
testicles <strong>the</strong> same size? Do <strong>the</strong>y hurt? Include any o<strong>the</strong>r necessary details in <strong>the</strong> explanation box<br />
after question #21.<br />
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DISCLOSURE & CONSENT INFORMATION<br />
<strong>UIL</strong> PREPARTICIPATION EVALUATION - MEDICAL HISTORY FORM<br />
It is unders<strong>to</strong>od that even though protective equipment is worn by <strong>the</strong> athlete, whenever needed,<br />
<strong>the</strong> possibility of an accident still remains. Nei<strong>the</strong>r <strong>the</strong> University Interscholastic League nor <strong>the</strong><br />
school assumes any responsibility in case an accident occurs.<br />
If, in <strong>the</strong> judgment of any representative of <strong>the</strong> school, <strong>the</strong> above student should need immediate<br />
care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent<br />
<strong>to</strong> such care and treatment as may be given said student by any physician, athletic trainer, nurse or<br />
school representative. I do hereby agree <strong>to</strong> indemnify and save harmless <strong>the</strong> school and any school<br />
or hospital representative from any claim by any person on account of such care and treatment of<br />
said student.<br />
If, between this date and <strong>the</strong> beginning of athletic competition, any illness or injury should occur that<br />
may limit this student's participation, I agree <strong>to</strong> notify <strong>the</strong> school authorities of such illness or injury.<br />
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<br />
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DISCLOSURE & CONSENT INFORMATION<br />
<strong>UIL</strong> PREPARTICIPATION EVALUATION - MEDICAL HISTORY FORM<br />
Any Yes answer <strong>to</strong> questions 1, 2, 3, 4, 5, or 6 requires fur<strong>the</strong>r medical evaluation<br />
which may include a physical examination. Written clearance from a physician,<br />
physician assistant, chiroprac<strong>to</strong>r, or nurse practitioner is required before any<br />
participation in <strong>UIL</strong> practices, games or matches. THIS FORM MUST BE ON FILE<br />
PRIOR TO PARTICIPATION IN ANY PRACTICE, SCRIMAGE OR CONTEST BEFORE,<br />
DURING OR AFTER SCHOOL.<br />
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BACK PAGE<br />
<strong>UIL</strong> PREPARTICIPATION EVALUATION - MEDICAL HISTORY FORM<br />
ONLY complete <strong>the</strong> <strong>to</strong>p line (Student’s Name, Sex, Age and Date of Birth) on <strong>the</strong><br />
back page of <strong>the</strong> <strong>Medical</strong> His<strong>to</strong>ry <strong>Form</strong>. Everything else below <strong>the</strong> <strong>to</strong>p line will be<br />
filled out by <strong>the</strong> doc<strong>to</strong>r during <strong>the</strong> actual physical evaluation.<br />
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