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Fill in a Valid Alabama High School Physical Form

The Alabama High School Physical form is a crucial document required for student athletes in Alabama to ensure their health and safety before participating in sports. This form collects detailed information about the athlete's medical history and current health status, allowing physicians to assess their fitness for athletic activities. Proper completion and submission of this form are essential for compliance with state regulations governing interscholastic athletics.

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Fill in a Valid Alabama High School Physical Form

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Document Sample

ALABAMA HIGH SCHOOL ATHLETIC ASSOCIATION	Revised 2018
Revised 2018	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?
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
			Student's name		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
Physical Examination					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			Revised 2018
			Vision R 20 / ____ L 20 / ____ Corrected: Y N

		LIMITED		Normal		Abnormal Findings

			Cardiovascular
			Cardiovascular

			Pulses

			Heart

			Lungs

			Skin

			E.N.T.

	COMPLETE		Abdominal

			Genitalia (males)
			Genitalia (males)

			Musculoskeletal

			Neck

			Shoulder

			Elbow

			Wrist

			Hand

			Back

			Knee

			Ankle

			Foot

			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.)

Rev. 2018 (The revised 2018 form is the official form accepted by the AHSAA.)

Document Information

Fact Name	Details
Governing Law	The Alabama High School Athletic Association (AHSAA) Rule 1, Sec. 14 mandates that a current physician's statement must be on file for student-athletes.
Eligibility Requirement	Students in grades 7-12 must pass a physical exam to be eligible for interscholastic athletics.
Form Usage	The AHSAA Physicians Certificate (Form 5) is the required document to certify a student's physical exam.
Physical Exam Validity	A physical exam is valid for one calendar year from the date of the exam.
Evaluation Findings	Physicians can clear students for participation, require rehabilitation, or deny clearance based on their evaluation.
Information Collected	The form collects personal information, medical history, and details about previous injuries or conditions.

Alabama High School Physical - Usage Guidelines

Filling out the Alabama High School Physical form is an important step in ensuring that a student athlete is ready for participation in sports. This process involves providing personal information, answering medical history questions, and obtaining a physician's evaluation. Following the steps carefully will help ensure that all necessary information is accurately captured.

Gather Necessary Information: Before starting the form, collect the athlete's personal details, including name, age, address, school, and grade.
Complete the Medical History Section: Answer all questions regarding past medical issues, injuries, and current health conditions. Be honest and thorough in your responses.
Detail Any "Yes" Responses: If any questions in the medical history section are answered with "Yes," provide explanations in the space provided. Include details about the condition, dates, and any treatments received.
Provide Contact Information: Fill in the athlete's date of birth and phone number. This information is crucial for emergency contact purposes.
Sign the Form: The athlete should sign and date the form to affirm that all information is accurate. A parent or guardian must also sign and date the form, acknowledging the information provided.
Schedule a Physical Examination: Take the completed form to a physician (M.D. or D.O.) for a physical examination. The physician will complete the evaluation section of the form.
Physician's Certification: Ensure the physician signs and dates the form, indicating whether the athlete is cleared for participation in sports.
Submit the Form: Once completed, submit the signed form to the school’s Superintendent or Principal’s office. This should be done before the athlete can participate in any interscholastic athletics.

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Dos and Don'ts

When filling out the Alabama High School Physical form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are seven things you should and shouldn't do:

Do provide accurate personal information, including your name, age, and address.
Do answer all medical history questions truthfully, including any past injuries or conditions.
Do have a parent or guardian review the form before submission if you are under 18.
Do ensure that the physician's signature is included and dated.
Don't leave any sections blank; all questions must be answered.
Don't forge signatures or provide false information, as this can lead to disqualification.
Don't forget to make a copy of the completed form for your records.

Common mistakes

Incomplete Personal Information: Failing to provide complete personal details such as name, age, and address can lead to delays in processing the form. It is essential to ensure that all sections are filled out accurately.
Neglecting Medical History: Omitting past medical conditions or injuries can jeopardize the athlete's safety. It is crucial to disclose any history of concussions, surgeries, or chronic conditions.
Incorrect Signatures: The form requires signatures from both the athlete and a parent or guardian. Missing one of these signatures can render the form invalid.
Failure to Update Information: Submitting an outdated physical examination can result in ineligibility for participation. Athletes must ensure that the physical is current, as it is valid for only one calendar year.
Ignoring Additional Instructions: Not following specific instructions regarding the physical examination or additional documentation can lead to complications. Athletes should carefully read and adhere to all guidelines provided on the form.

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