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:
Work:
Cellular:
Next of Kin:
First Name
Last Name
Relation:
Home:
Work:
Cellular:
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
Asthma
13
14
HEART AND LUNGS
NO
AT REST
DURING/AFTER EXERCISE
Chest pain or tightness
15
16
17
Palpitations/Arrhythmias
Other heart problems
18
19
20
Respiratory problems
Dizziness
21
22
23
Syncope
24
25
26
ADDITIONAL HEART AND LUNGS
NO
YES
Hypertension
27
28
Heart murmurs
29
30
Abnormal lipid profile
31
32
Seizures, Epilepsy
33
34
Advised to give up sport
35
36
Tired more quickly than team-mates
37
38
Blood pressure reading (mmHg)
Pulse (bpm)
Respiratory rate
SpO2 Reading (%)
Blood Glucose (mg/dl or mmol/l)
Additional notes:
MUSCULOSKELETAL SYSTEM
NOT APPLICABLE
39
Severe injury leading to more than four weeks of limited participation or absence from playing/training:
RIGHT
LEFT
MOST RECENT OCCURRENCE (YEAR)
Groin strain
40
41
strain of quadriceps femurs muscles
42
43
Hamstring strain
44
45
Knee ligament injury
46
47
Ankle ligament
48
49
Other (please specify below)
50
51
Other:
MUSCILOSKELTAL SURGERY
Not applicable
MUSCULOSKELETAL SURGERY
RIGHT
LEFT
MOST RECENT OPERATION (when?) YEAR
Hip joint
52
53
Groin
54
55
Knee ligaments
56
57
Knee meniscus or cartilage
58
59
Achilles tendon
60
61
Ankle joint
62
63
Other operations (please specify below)
64
65
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
Knee
ADDITIONAL BODY PARTS
RIGHT
LEFT
Hip
66
67
Groin
68
69
Thigh
70
71
Knee
72
73
Lower leg
74
75
Achilles tendon
76
77
Ankle
78
79
Foot, toe
80
81
CURRENT DIAGNOSIS AND TREATMENT
Not applicable
CURRENT DIAGNOSIS AND TREATMENT
RIGHT
LEFT
REST
PHYSIOTHERAPY
SURGERY
Groin
82
83
84
85
86
Hamstring strain
87
88
89
90
91
Quadriceps strain
92
93
94
95
96
Knee sprain
97
98
99
100
101
Meniscus lesion
102
103
104
105
106
Tendinosis of Achilles tendon
107
108
109
110
111
Ankle sprain
112
113
114
115
116
Concussion
117
118
119
120
121
Lower back pain
122
123
124
125
126
FAMILY HISTORY (Male relatives
NO
FATHER
MOTHER
SIBLING
OTHER
Sudden cardiac death
127
128
129
130
131
Sudden infant death (SID)
132
133
134
135
136
Coronary heart disease
137
138
139
140
141
Cardiomyopathy
142
143
144
145
146
Hypertension
147
148
149
150
151
Recurrent syncope
152
153
154
155
156
Arrhythmia
157
158
159
160
161
Heart transplant
162
163
164
165
166
Heart surgery
167
168
169
170
171
Pacemaker/defibrillator
172
173
174
175
176
Marfan syndrome
177
178
179
180
181
Unexplained drowning
182
183
184
185
186
Unexplained car accident
187
188
189
190
191
Stroke
192
193
194
195
196
Diabetes
197
198
199
200
201
Cancer
202
203
204
205
206
Other (arthritis etc)
207
208
209
210
211
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
212
213
214
SACROILIAC JOINT
Normal
Abnormal
CERVICAL ROTATION
DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
215
216
LEFT
217
218
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
219
220
221
LEFT
222
223
224
EXTENSION (passive)
NORMAL
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
225
226
227
LEFT
228
229
230
INWARD ROTATION (in 90º flexion)
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
231
232
LEFT
233
234
OUTWARD ROTATION (in 90º flexion)
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
235
236
LEFT
237
238
ABDUCTION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
239
240
LEFT
241
242
TENDERNESS ON GROIN PALPATION
NO
PUBIS
INGUINAL CANAL
RIGHT
243
244
245
LEFT
246
247
248
HERNIA
NO
YES, PLEASE SPECIFY BELOW
RIGHT
249
250
LEFT
251
252
HERNIA SPECIFICS
MUSCLES
ADDUCTORS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
253
254
255
256
LEFT
257
258
259
260
HAMSTRINGS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
261
262
263
264
LEFT
265
266
267
268
ILIOPOAS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
269
270
271
272
LEFT
273
274
275
276
RECTUS FEMORIS
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
277
278
279
280
LEFT
281
282
283
284
TENSOR FASCIAE LATAE MUSCLE (iliotibial band)
NORMAL
SHORTENED
PAINFUL (NO)
PAINFUL (YES)
RIGHT
285
286
287
288
LEFT
289
290
291
292
EXAMINATION OF KNEES
KNEE-JOINT AXIS
NORMAL
GENU VARUM
GENU VALGUM
RIGHT
293
294
295
LEFT
296
297
298
FLEXION (passive)
NORMAL
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
299
300
301
LEFT
302
303
304
EXRTENSION (passive)
0º
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
HYPEREXTENSION DEGREES (º)
RIGHT
305
306
307
308
LEFT
309
310
311
312
LACHMAN TEST
NORMAL
+
++
+++
RIGHT
313
314
315
316
LEFT
317
318
319
320
ANTERIOR DRAWER SIGN (knee joint 90º flexion)
NORMAL
+
++
+++
RIGHT
321
322
323
324
LEFT
325
326
327
328
POSTERIOR DRAWER SIGN (knee joint 90º flexion)
NORMAL
+
++
+++
RIGHT
329
330
331
332
LEFT
333
334
335
336
VALGUS STRESS, IN EXTENSION
NORMAL
+
++
+++
RIGHT
337
338
339
340
LEFT
341
342
343
344
VALGUS STRESS, IN 30º FLEXION
NORMAL
+
++
+++
RIGHT
345
346
347
348
LEFT
349
350
351
352
VARUS STRESS, IN EXTENSION
NORMAL
+
++
+++
RIGHT
353
354
355
356
LEFT
357
358
359
360
VARUS STRESS, IN 30º FLEXION
NORMAL
+
++
+++
RIGHT
361
362
363
364
LEFT
365
366
367
368
JOINT LINE TENDERNESS
NORMAL
+
++
+++
RIGHT MEDIAL
369
370
371
372
RIGHT LATERAL
373
374
375
376
LEFT MEDIAL
377
378
379
380
LEFT LATERAL
381
382
383
384
EXAMINATION OF LOWER LEG, ANKLE AND FOOT
TENDERNESS OF ACHILLES TENDON
NO
YES
RIGHT
385
386
LEFT
387
388
ANTERIOR DRAWER SIGN
NORMAL
+
++
+++
RIGHT
389
390
391
392
LEFT
393
394
395
396
DORSI-FLEXION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
397
398
LEFT
399
400
PLANTAR FLEXION
LIMITED DEGREES (º)
PAINFUL (NO)
PAINFUL (YES)
RIGHT
401
402
LEFT
403
404
TOTAL SUPINATION
NORMAL
DECREASED
INCREASED
RIGHT
405
406
407
LEFT
408
409
410
TOTAL PRONATION
NORMAL
DECREASED
INCREASED
RIGHT
411
412
413
LEFT
414
415
416
METATARSOPHALANGEAL JOINT
NORMAL
PATHOLOGICAL
RIGHT
417
418
LEFT
419
420
NAME OF EXAMINING PERSON
First Name
Last Name
Phone Number
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Signature
Submit
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