Form and Protocol for Sports Physical Examinations

Created by CH on 2-10-10

581-021-0041

Form and Protocol for Sports Physical Examinations

The State Board of Education adopts by reference the form entitled "School Sports Pre-Participation Examination June 2004 May 2010" that must be used to document the physical examination and the document entitled "School Sports Pre-Participation Examination Protocol June 2004" that sets out the protocol for conducting the physical examination.

The State Board of Education adopts by reference the form entitled "School Sports Pre-Participation Examination” and dated May 2010. Medical providers authorized under ORS 336.479 to conduct a physical examination must use this form to document the physical examination. Medical providers must also use the protocol set forth on this form for conducting the physical examination.

Stat. Auth: ORS 326.051
Stats. Implemented: ORS 336.479

Physical ExaminationSchool Sports Pre-Participation Examination – Part 1: Student or Parent Completes

BoldItalic indicatesproposedchangestothisform.

NAME:BIRTHDATE://

ADDRESS:PHONE:()

AthleteandParent/Guardian:Pleasereviewallquestionsandanswerthemtothebestofyourability.

Physician:Pleasereviewwiththeathletedetailsofanypositiveanswers.

YESNODon’tKnow

1. Hasanyoneintheathlete’sfamilydiedsuddenlybeforetheageof50years?

2. Hastheathleteeverpassedoutduringexerciseorstoppedexercisingbecauseofdizzinessorchestpain?

3. Doestheathletehaveasthma(wheezing),hayfever,orotherallergies?

4. Hastheathleteeverbrokenabone,hadtowearacast,orhadaninjurytoanyjoint?

5. Hastheathleteeverhadaheadinjuryorconcussion?

6. Hastheathleteeverhadahitorblowtotheheadthatcausedconfusion,prolongedheadacheormemoryproblems?

7. Hastheathleteeversufferedaheat-relatedillness(heatstroke)?

8. Doestheathletehaveachronicillnessorseeaphysicianregularlyforanyparticularproblem?

9. Doestheathletetakeanyprescribedmedicine,herbsornutritionalsupplements?

10. Istheathleteallergictoanymedicationsorbeestings?

11. Doestheathletehaveonlyoneofanypairedorgan(eyes,kidneys,testicles,ovaries,etc.)?

12. Hastheathleteeverhadpriorlimitationfromsportsparticipation?

13. Hastheathletehadanyepisodesofshortnessofbreath,palpitations,historyofrheumaticfeverortiringeasily?

14. Hastheathleteeverbeendiagnosedwithaheartmurmurorheartconditionorhypertension?

15. Isthereahistoryofyoungpeopleintheathlete'sfamilywhohavehadcongenitalorotherheartdisease:

cardiomyopath,abnormalheartrhythms,longQTorMarfan'ssyndrome? (Youmaywrite"Idon'tunderstandtheseterms"

andinitialthisitem,ifappropriate.)

16. Hastheathleteeverbeenhospitalizedovernightorhadsurgery?

17. Doestheathleteloseweightregularlytomeettherequirementsforyoursport?

18. Doestheathletehaveanythingheorshewantstodiscusswiththephysician?

19. Doestheathletecough,wheeze,orhavetroublebreathingduringorafteractivity?

(ExplainanyYESanswersonback.)

20. Areyouhappywithyourweight?

21. FEMALESONLY

a.Whenwasyourfirstmenstrualperiod?

b.Whenwasyourmostrecentmenstrualperiod?

c.Whatwasthelongesttimebetweenmenstrualperiodsinthelastyear?

Parent/Guardian’sStatement:

Ihavereviewedandansweredthequestionsabovetothebestofmyability. Iandmychildunderstandandacceptthattherearerisksofseriousinjuryanddeathinanysport,including theone(s)inwhichmychildhaschosentoparticipate. Iherebygivepermissionformychildtoparticipateinsports/activities.

Iherebyauthorizeemergencymedicaltreatmentand/ortransportationtoamedicalfacilityforanyinjuryorillnessdeemedurgentlynecessarybyalicensedathletictrainer,coach,or medicalpractitioner.

Iunderstandthatthissportspre-participationphysicalexaminationisnotdesignednorintendedtosubstituteforanyrecommendedregularcomprehensivehealthassessment.

Iherebyauthorizereleaseoftheseexaminationresultstomychild'sschool.

Signed: Date:

Parent/Guardian

AsperORS336.479,Section1(3)"Aschooldistrictshallrequirestudentswhocontinuetoparticipateinextracurricularsportsingrades7through12tohaveaphysicalexaminationonce everytwoyears." Section1(5)“Anyphysicalexaminationrequiredbythissectionshallbeconductedbya(a)physicianpossessinganunrestrictedlicensetopracticemedicine;(b)licensednaturopathicphysician;(c)licensedphysicianassistant;(d)certifiednursepractitioner;ora(e)licensedchiropracticphysicianwhohasclinicaltrainingandexperienceindetecting cardiopulmonarydiseasesanddefects.”

Revised May 2010

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SchoolSportsPre-ParticipationExamination – Part 2 Medical Provider Completes

NAME:BIRTHDATE://

Height:Weight:

%BodyFat(optional):

Pulse:BP:

____/____ (____/____,____/____)

Vision: R20/_____ L20/_____Corrected:Y NPupils: Equal_____ Unequal_____

Rhythm: Regular_____Irregular_____

MEDICAL / NORMAL / ABNORMALFINDINGS / INITIALS*
Appearance
Eyes/Ears/Nose/Throat
LymphNodes
Heart:Pericardialactivity
1st2ndheartsounds
Murmurs
Pulses:brachial/femoral
Lungs
Abdomen
Skin

MUSCULOSKELETAL

*Station-basedexaminationonly

Cleared

Clearedaftercompletingevaluation/rehabilitationfor: Notclearedfor:

Recommendations:

CLEARANCE

Reason:

Nameofphysician(print/type):

Date://

Address:Phone: ()

SignatureofPhysician:

Revised May 2010

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SUGGESTED EXAMPROTOCOL FOR THE PHYSICIAN

MUSCULOSKELETAL

Havepatient:Tocheckfor:

1.StandfacingexaminerACjoints,generalhabitus

2.Lookatceiling,floor,overshoulders,touchearstoshouldersCervicalspinemotion

3.Shrugshoulders(againstresistance)Trapeziusstrength

4.Abductshoulders90degrees,holdagainstresistanceDeltoidstrength

5.ExternallyrotatearmsfullyShouldermotion

6.FlexandextendelbowsElbowmotion

7.Armsatsides,elbows90degreesflexed,pronate/supinatewristsElbowandwristmotion

8.Spreadfingers,makefistHandandfingermotion,deformities

9.Contractquadriceps,relaxquadricepsSymmetryandknee/ankleeffusion

10.“Duckwalk”4stepsawayfromexaminerHip,kneeandanklemotion

11.StandwithbacktoexaminerShouldersymmetry,scoliosis

12.Kneesstraight,touchtoesScoliosis,hipmotion,hamstrings

13.Riseuponheels,thentoesCalfsymmetry,legstrength

MURMUR EVALUATION – Auscultation should be performed sitting, supine and squaring in a quiet room using the diaphragm and bell of a stethoscope.

Auscultationfindingof:Rulesout:

1.S1heardeasily;notholosystolic,soft,low-pitchedVSDandmitralregurgitation

2.NormalS2Tetralogy,ASDandpulmonaryhypertension

3.Noejectionormid-systolicclickAorticstenosisandpulmonarystenosis

4.ContinuousdiastolicmurmurabsentPatentductusarteriosus

5.NoearlydiastolicmurmurAorticinsufficiency

6.NormalfemoralpulsesCoarctation

(Equivalenttobrachialpulsesinstrengthandarrival)

MARFAN’S SCREEN – Screen all men over 6’0” and all women over 5’10” in height with echocardiogram and slit lamp exam when any two of the following are found:

1.FamilyhistoryofMarfan’ssyndrome(thisfindingaloneshouldpromptfurtherinvestigation)

2.Cardiacmurmurormid-systolicclick

3.Kyphoscoliosis

4.Anteriorthoracicdeformity

5.Armspangreaterthanheight

6.Uppertolowerbodyratiomorethan1SDbelowmean

7.Myopia

8.Ectopiclens

CONCUSSION -- When can an athlete return to play after a concussion?

After suffering a concussion, no athlete should return to play or practice on the same day. Previously, athletes were allowed to return to play if their symptoms resolved within 15 minutes of the injury. Studies have shown that the young brain does not recover that quickly, thus the Oregon Legislature has established a rule that no player shall return to play following a concussion on that same day and the athlete must be cleared by an appropriate health care professional before they are allowed to return to play or practice.

Once an athlete is cleared to return to play they should proceed with activity in a stepwise fashion to allow their brain to readjust to exertion. The athlete may complete a new step each day. The return to play schedule should proceed as below following medical clearance:

Step 1:Lightexercise,includingwalkingorridinganexercisebike. Noweightlifting. Step 2:Runninginthegymoronthefield. Nohelmetorotherequipment.

Step 3:Non-contacttrainingdrillsinfullequipment. Weighttrainingcanbegin. Step 4:Fullcontactpracticeortraining.

Step 5:Gameplay.

Ifsymptomsoccuratanystep,theathleteshouldceaseactivityandbere-evaluatedbyahealthcareprovider.

Last Revised May 2010

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