PRE-COMPETITION MEDICAL ASSESSMENT(PCMA)
PLAYER:
Name
First Name
Last Name
Gender:
Male
Female
Age:
Date of Birth:
-
Month
-
Day
Year
Date
Club:
School/Job:
Employer:
Sport:
Next of Kin:
First Name
Last Name
Relation:
Home:
-
Area Code
Phone Number
Work:
-
Area Code
Phone Number
Cellular:
-
Area Code
Phone Number
Next of Kin:
First Name
Last Name
Relation:
Home:
-
Area Code
Phone Number
Work:
-
Area Code
Phone Number
Cellular:
-
Area Code
Phone Number
Date of Assessment:
-
Month
-
Day
Year
Date
MEDICAL HISTORY
PRESENT AND PAST COMPLAINTS
GENERAL
NO
YES
Infections (esp. Viral) (within the last four weeks)
1
2
Diarrhea illness
3
4
Rheumatic fever
5
6
Heat illness
7
8
Concussion
9
10
Allergies
11
12
HEART AND LUNGS
NO
AT REST
DURING/AFTER EXERCISE
Chest pain or tightness
13
14
15
Palpitations/Arrhythmias
Other heart problems
16
17
18
Respiratory problems
Dizziness
19
20
21
Syncope
22
23
24
ADDITIONAL HEART AND LUNGS
NO
YES
Hypertension
25
26
Heart murmurs
27
28
Abnormal lipid profile
29
30
Seizures, Epilepsy
31
32
Advised to give up sport
33
34
Tired more quickly than team-mates
35
36
Additional notes:
MUSCULOSKELETAL SYSTEM
NOT APPLICABLE
37
Severe injury leading to more than four weeks of limited participation or absence from playing/training:
RIGHT
LEFT
MOST RECENT OCCURRENCE (YEAR)
Groin strain
38
39
strain of quadriceps femurs muscles
40
41
Hamstring strain
42
43
Knee ligament injury
44
45
Ankle ligament
46
47
Other (please specify below)
48
49
Other:
MUSCILOSKELTAL SURGERY
Not applicable
MUSCULOSKELETAL SURGERY
RIGHT
LEFT
MOST RECENT OPERATION (when?) YEAR
Hip joint
50
51
Groin
52
53
Knee ligaments
54
55
Knee meniscus or cartilage
56
57
Achilles tendon
58
59
Ankle joint
60
61
Other operations (please specify below)
62
63
Other:
Current complaint aches or pains:
NO
YES, Please specify body parts
BODY PARTS
Head/face
Cervical spine
Thoracic spine
Lumbar spine
Sternum/ribs
Abdomen
Pelvis/sacrum
Shoulder
Upper arm
Elbow
Forearm
Wrist
Hand
Fingers
ADDITIONAL BODY PARTS
RIGHT
LEFT
Hip
64
65
Groin
66
67
Thigh
68
69
Knee
70
71
Lower leg
72
73
Achilles tendon
74
75
Ankle
76
77
Foot, toe
78
79
CURRENT DIAGNOSIS AND TREATMENT
Not applicable
CURRENT DIAGNOSIS AND TREATMENT
RIGHT
LEFT
REST
PHYSIOTHERAPY
SURGERY
Groin
80
81
82
83
84
Hamstring strain
85
86
87
88
89
Quadriceps strain
90
91
92
93
94
Knee sprain
95
96
97
98
99
Meniscus lesion
100
101
102
103
104
Tendinosis of Achilles tendon
105
106
107
108
109
Ankle sprain
110
111
112
113
114
Concussion
115
116
117
118
119
Lower back pain
120
121
122
123
124
FAMILY HISTORY (Male relatives
NO
FATHER
MOTHER
SIBLING
OTHER
Sudden cardiac death
125
126
127
128
129
Sudden infant death (SID)
130
131
132
133
134
Coronary heart disease
135
136
137
138
139
Cardiomyopathy
140
141
142
143
144
Hypertension
145
146
147
148
149
Recurrent syncope
150
151
152
153
154
Arrhythmia
155
156
157
158
159
Heart transplant
160
161
162
163
164
Heart surgery
165
166
167
168
169
Pacemaker/defibrillator
170
171
172
173
174
Marfan syndrome
175
176
177
178
179
Unexplained drowning
180
181
182
183
184
Unexplained car accident
185
186
187
188
189
Stroke
190
191
192
193
194
Diabetes
195
196
197
198
199
Cancer
200
201
202
203
204
Other (arthritis etc)
205
206
207
208
209
ROUTINE MEDICATION WITHIN THE LAST 12 MONTHS
Please specify
MUSCULOSKELETAL SYSTEM
SPINAL COLUMN AND PELVIC LEVEL
SPINAL FORM
Normal
Flat
Hyperkyphosis
Hyperlordosis
Scoliosis
PELVIC
EVEN
MEASUREMENTS (CM) LOWER
RIGHT
LEFT
PELVIC LEVEL
210
211
212
SACROILIAC JOINT
Normal
Abnormal
CERVICAL ROTATION
DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
213
214
LEFT
215
216
SPINAL FELXION
MEASUREMENTS (CM)
DISTANCE FINGERTIPS TO FLOOR
EXAMINATION OF HIPS, GROINS AND THIGHS
HIP FLEXIBILITY
FLEXION (passive)
NORMAL
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
217
218
219
LEFT
220
221
222
EXTENSION (passive)
NORMAL
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
223
224
225
LEFT
226
227
228
INWARD ROTATION (in 90º flexion)
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
229
230
LEFT
231
232
OUTWARD ROTATION (in 90º flexion)
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
233
234
LEFT
235
236
ABDUCTION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
237
238
LEFT
239
240
TENDERNESS ON GROIN PALPATION
NO
PUBIS
INGUINAL CANAL
RIGHT
241
242
243
LEFT
244
245
246
HERNIA
NO
YES, PLEASE SPECIFY BELOW
RIGHT
247
248
LEFT
249
250
HERNIA SPECIFICS
MUSCLES
ADDUCTORS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
251
252
253
254
LEFT
255
256
257
258
HAMSTRINGS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
259
260
261
262
LEFT
263
264
265
266
ILIOPOAS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
267
268
269
270
LEFT
271
272
273
274
RECTUS FEMORIS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
275
276
277
278
LEFT
279
280
281
282
TENSOR FASCIAE LATAE MUSCLE (iliotibial band)
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
283
284
285
286
LEFT
287
288
289
290
EXAMINATION OF KNEES
KNEE-JOINT AXIS
NORMAL
GENU VARUM
GENU VALGUM
RIGHT
291
292
293
LEFT
294
295
296
FLEXION (passive)
NORMAL
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
297
298
299
LEFT
300
301
302
EXRTENSION (passive)
0º
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
HYPEREXTENSION DEGREES (º)
RIGHT
303
304
305
306
LEFT
307
308
309
310
LACHMAN TEST
NORMAL
+
++
+++
RIGHT
311
312
313
314
LEFT
315
316
317
318
ANTERIOR DRAWER SIGN (knee joint 90º flexion)
NORMAL
+
++
+++
RIGHT
319
320
321
322
LEFT
323
324
325
326
POSTERIOR DRAWER SIGN (knee joint 90º flexion)
NORMAL
+
++
+++
RIGHT
327
328
329
330
LEFT
331
332
333
334
VALGUS STRESS, IN EXTENSION
NORMAL
+
++
+++
RIGHT
335
336
337
338
LEFT
339
340
341
342
VALGUS STRESS, IN 30º FLEXION
NORMAL
+
++
+++
RIGHT
343
344
345
346
LEFT
347
348
349
350
VARUS STRESS, IN EXTENSION
NORMAL
+
++
+++
RIGHT
351
352
353
354
LEFT
355
356
357
358
VARUS STRESS, IN 30º FLEXION
NORMAL
+
++
+++
RIGHT
359
360
361
362
LEFT
363
364
365
366
JOINT LINE TENDERNESS
NORMAL
+
++
+++
RIGHT MEDIAL
367
368
369
370
RIGHT LATERAL
371
372
373
374
LEFT MEDIAL
375
376
377
378
LEFT LATERAL
379
380
381
382
EXAMINATION OF LOWER LEG, ANKLE AND FOOT
TENDERNESS OF ACHILLES TENDON
NO
YES
RIGHT
383
384
LEFT
385
386
ANTERIOR DRAWER SIGN
NORMAL
+
++
+++
RIGHT
387
388
389
390
LEFT
391
392
393
394
DORSI-FLEXION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
395
396
LEFT
397
398
PLANTAR FLEXION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
399
400
LEFT
401
402
TOTAL SUPINATION
NORMAL
DECREASED
INCREASED
RIGHT
403
404
405
LEFT
406
407
408
TOTAL PRONATION
NORMAL
DECREASED
INCREASED
RIGHT
409
410
411
LEFT
412
413
414
METATARSOPHALANGEAL JOINT
NORMAL
PATHOLOGICAL
RIGHT
415
416
LEFT
417
418
NAME OF EXAMINING PERSON
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Signature
Submit
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