Oregon Sports Participation Step 1 of 9 11% History FormDate of ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex AgeGrade School Sport(s) Medicines and Allergies:Please list all of the prescription and over‐the‐counter medicines and supplements (herbal and nutritional) that you are currently takingDo you have any allergies? Yes No If yes, please identify specific allergy below. Medicines Pollens Foods Stinging Insects General Questions1. When was the student’s last complete physical or “checkup?” (Ideally, every 12 months)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202. Has a doctor or other health professional ever denied or restricted your participation in sports for any reason?NoYes3. Do you have any ongoing medical conditions?NoYes4. Have you ever had surgery?NoYes HEART HEALTH QUESTIONS ABOUT YOU 5. Have you ever passed out or nearly passed out DURING or AFTER exercise?NoYes6. Have you ever had discomfort, pain, tightness or pressure in your chest during exercise?NoYes7. Does your heart ever race or skip beats (irregular beats) during exercise?NoYes8. Has a doctor ever told you that you have any heart problems?NoYesIf so, check all that apply: High blood pressure High cholesterol Kawasaki disease A heart murmur A heart infection Other If check other, please explain below: 9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)YesNo10. Do you get lightheaded or feel more short of breath than expected, or get tired more quickly than your friends or classmates during exercise?YesNo11. Have you ever had a seizure?YesNo HEART HEALTH QUESTIONS ABOUT YOUR FAMILY 12. Has any family member or relative died of heart problems or had an unexpected sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?YesNo13. Does anyone in your family have a pacemaker, an implanted defibrillator, or heart problems like hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?YesNo13. Does anyone in your family have a pacemaker, an implanted defibrillator, or heart problems like hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?YesNoBONE AND JOINT QUESTIONS14. Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice, game or an event?YesNo15. Do you have a bone, muscle or joint problem that bothers you?YesNo MEDICAL QUESTIONS16. Do you cough, wheeze or have difficulty breathing during or after exercise?YesNo17. Have you ever used an inhaler or taken asthma medicine?YesNo18. Are you missing a kidney, an eye, a testicle (males), your spleen or any other organ?YesNo19. Do you have any rashes, pressure sores, or other skin problems such as herpes or MRSA skin infection?YesNo20. Have you ever had a head injury or concussion?YesNo21. Have you ever had numbness, tingling, or weakness, or been unable to move your arms or legs after being hit or falling?YesNo22. Have you ever become ill while exercising in the heat?YesNo23. Do you or someone in your family have sickle cell trait or disease?YesNo24. Have you, or do you have any problems with your eyes or vision?YesNo25. Do you worry about your weight?YesNo26. Are you trying to or has anyone recommended that you gain or lose weight?YesNo27. Are you on a special diet or do you avoid certain types of food?YesNo28. Have you ever had an eating disorder?YesNo29. Do you have any concerns that you would like to discuss today?YesNo 30. Have you ever had a menstrual period?YesNo31. How old were you when you had your first menstrual period?32. How many periods have you had in the last 12 months? Explain “yes” answers here: I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.Signature of athlete Signature of parent/guardian DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ORS 336.479, Section 1 (3) "A school district shall require students who continue to participate in extracurricular sports in grades 7 through 12 to have a physical examination once every two years." Section 1(5) “Any physical examination required by this section shall be conducted by a (a) physician possessing an unrestricted license to practice medicine; (b) licensed naturopathic physician; (c) licensed physician assistant; (d) certified nurse practitioner; or a (e) licensed chiropractic physician who has clinical training and experience in detecting cardiopulmonary diseases and defects.” Δ
