AHSAA Pre-Participation Physical Evaluation Form

Athlete Information

Name*

Date of Birth*

Hidden

Age

Sex*

Female

Male

Address*

Phone Number*

School*

Grade*

Sport*

When was your first menstrual period?*

When was your last menstrual period?*

What was the longest time between your periods last year?*

Service Code

If your provider gave you a service code for this form, enter it here.

Form Processing Fee Required*

There is a $10 fee which must be paid to complete processing. Forms submitted without this fee will be discarded. See payment instructions on the next page.

I acknowledge that I must pay the processing fee for this form to be completed.

Signature of Athlete*

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Signature of Parent/Guardian*

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Name

This field is for validation purposes and should be left unchanged.

AHSAA Pre-Participation Physical Evaluation Form

Athlete Information

Health Questionnaire

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