Preparticipation Examination Survey

Institution:
e-mail:
Classification:
Title:
Phone:
Name:
Conference:
# of Sports
# of Student-Athletes:
# of Full-Time ATCs:
Frequency for which you provide PPEs (Full Examination)?
Walk-on student athletes obtain their PPE from the following:
Which of the following do you provide for ALL of your student-athletes?
The AHA (American Heart Association) has recommended the following as part of the athletic screening process, which of the following is part of your program's PPE?
Who is responsible for following up testing for cardiac referral, orthopaedic follow-up, nutritional and psychological counseling or other issues that are detected on the PPE?
Who provides the PPE for your student-athletes?
How many disqualifications have you had in the past two (2) years?
We have the following specialist on hand for our PPEs:
PPEs are performed at the ____________________.
What is the cost for providing your PPE examinations (i.e. additional staff, physicians, labs, diagnostics, etc.,)?
Do you provide an Exit Physical in addition to your Entrance Physical?
Do you provide a Recruiting Physical Examination?
Which Sports?
If Other the Who?
Family History
Personal History
Physical Examination
What is the biggest difficulty in providing a quality PPE?
YesNo
YesNo
Family Physician
Team Physician
Health Services
Other:
EKG
Echocardiogram
Sickle Cell Screening
Baseline Neuropsychological Test (Concussion)
HIV / Aids Screening
Other Hematological Labs
Eating Disorder / Nutritional Screening
Drug Testing
Urine Analysis: Protein, Specific Gravity, Blood
History of premature sudden cardiac death
History of heart disease in surviving relatives less than 50 years old
Hear mumor
Systemic hypertension
Fatigue
Syncope / near-syncope
Excessive / unexplained exertional dyspnea
Exertional chest pain
Heart mumor (supine / standing)
Femoral arterial pulses (to exclude coarctation of aorta)
Brachial blood pressure measurement (sitting)
Orthopaedic Surgeon
Internal Medicine / Family Medicine Physician
Cardiologist
Opthalmoligst / Optometrist
Neurologist
ENT
Chiropractor
Physical Therapist
Pediarist
Nutritionist / Sports Psychologist