The Alabama High School Physical form is a crucial document required for students participating in interscholastic athletics. This form ensures that athletes undergo a comprehensive physical examination, confirming their fitness for sports activities. It includes personal information, medical history, and a physician's evaluation, all aimed at safeguarding the health and well-being of young athletes.
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ALABAMA HIGH SCHOOL ATHLETIC ASSOCIATION
Revised 2018
Preparticipation Physical Evaluation Form
History
Date_______________________
Name__________________________________________________ Sex ________ Age______ Date of birth _______________
Address ______________________________________________________________________ Phone______________________
School ________________________________________________________Grade __________ Sport ______________________
Explain “Yes” answers below:
Yes
No
1.
Has a doctor ever restricted/denied your participation in sports?
2.
Have you ever been hospitalized or spent a night in a hospital?
Have ever had surgery?
3.
Do you have any ongoing medical conditions (like Diabetes or Asthma)?
4.
Are you presently taking any medications or pills (prescription or over‐the‐counter?
5.
Do you have any allergies (medicine, pollens, foods, bees or other stinging insects)?
6.
Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain or discomfort in your chest during or after exercise?
Do you tire more quickly than your friends during exercise?
Have you ever had high blood pressure?
Have you ever been told that you have a heart murmur, high cholesterol, or heart infection?
Have you ever had racing of your heart or skipped heartbeats?
Has anyone in your family died of heart problems or a sudden death before age 50?
Does anyone in your family have a heart condition?
Has a doctor ever ordered a test on your heart (EKG, echocardiogram)?
7.
Do you have any skin problems (itching, rashes, staph, MRSA, acne)?
8.
Have you ever had a head injury or concussion?
Have you ever been knocked out or unconscious?
Have you ever had a seizure?
Have you ever had a stinger, burner, pinched nerve, or loss of feeling or weakness in your arms or legs?
9.
Have you ever had heat or muscle cramps?
Have you ever been dizzy or passed out in the heat?
10. Do you have trouble breathing or do you cough during or after activity?
Do you take any medications for asthma (for instance, inhalers)?
11. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guards, etc.)?
12. Have you had any problems with your eyes or vision?
Do you wear glasses or contacts or protective eye wear?
13. Have you had any other medical problems (infectious mononucleosis, diabetes, infectious diseases, etc.)?
14. Have you had a medical problem or injury since your last evaluation?
15. Have you ever been told you have sickle cell trait?
Has anyone in your family had sickle cell disease or sickle cell trait?
16. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other
injuries of any bones or joints?
Head
Back
Shoulder
Forearm
Hand
Hip
Knee
Ankle
Neck
Chest
Elbow
Wrist
Finger
Thigh
Shin
Foot
17.When was your first menstrual period?__________________________________________________________________
When was your last menstrual period?___________________________________________________________________
What was the longest time between your periods last year?________________________________________________
Explain “Yes” answers:
______________________________________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of athlete ___________________________________________________________ Date ___________________
Signature of parent/guardian __________________________________________________
FORM 5
DUPLICATE AS NEEDED
Rev. 2018 (The revised 2018 form is the official form accepted by the AHSAA.)
Page 1 of 2
Preparticipation Physical Evaluation Rule 1, Sec. 14 — In order for a student to be eligible for interscholastic athletics, there must be
on file in the Superintendent’s or Principal’s office a current physician’s statement certifying that
__________________________________________ the student has passed a physical exam, and that in the opinion of the examining physician (M.D.
Student's name
or D.O.) the student is fully able to participate in interscholastic athletics (Grade s 7‐12). The
AHSAA Physicians Certificate (Form 5 Rev. 2018) must be used. A physical exam will satisfy the
Physical Examination
requirement for one calendar year through the end of the month from the date of the exam. For
example, a physical given on May 5, 2019, will satisfy the requirement through May 31, 2020.
Height ____________ Weight _____________ BP _____ / _____ Pulse ____________
Vision R 20 / ____ L 20 / ____ Corrected: Y N
LIMITED
Normal
Abnormal Findings
Cardiovascular
Pulses
Heart
Lungs
Skin
E.N.T.
COMPLETE
Abdominal
Genitalia (males)
Musculoskeletal
Other
Clearance:
A.Cleared
B.Cleared after completing evaluation/rehabilitation for: _______________________________________
C. Not cleared for:
Collision
Contact
Noncontact ____ Strenuous
____ Moderately strenuous
____ Nonstrenuous
Due to: ____________________________________________________________________________________________
Recommendation: _________________________________________________________________________________________
________________________________________________________________________________________________________
Name of physician ________________________________________________________________ Date ____________________
Address ________________________________________________________________________ Phone___________________
.
Signature of physician _____________________________________________________________, M.D. or D.O.
(Form must be signed and dated by the attending physician.)
When preparing for athletic participation in Alabama high schools, several documents work alongside the Alabama High School Physical form. These forms ensure that students are medically fit and meet all necessary requirements for safe participation in sports. Below is a list of common forms that may be needed.
Having these forms completed and on file is important for the safety and well-being of student athletes. Each document plays a vital role in ensuring that students are ready to compete and enjoy their sports safely.