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New Jersey Department of Education ANNUAL ATHLETIC PARTICIPATION PHYSICAL EXAMINATION FORM Part A: HEALTH HISTORY QUESTIONNAIRECompleted by the parent and student and reviewed by examining provider

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How to fill out part a health history

01

To fill out part A health history, follow these steps:

02

Begin by providing your personal information, such as your full name, date of birth, and contact details.

03

Next, fill in any existing medical conditions you have or have had in the past. Include details about any chronic illnesses, surgeries, or hospitalizations.

04

Specify any medications you are currently taking, including the dosage and frequency. Also, mention any allergies or sensitivities to medications.

05

Provide information about your family medical history, such as any genetic disorders or diseases that run in your family.

06

Answer the questions regarding your lifestyle choices, such as smoking, drinking alcohol, or drug usage.

07

If applicable, mention any pre-existing conditions related to pregnancy or reproductive health.

08

Finally, review your answers and make sure all information is accurate and up-to-date before submitting the health history form.

Who needs part a health history?

01

Anyone seeking medical care or undergoing a medical procedure may need to fill out part A health history. This includes patients visiting a new doctor, hospital, or healthcare facility for the first time. Additionally, individuals participating in clinical trials, insurance applications, or any situation where comprehensive medical information is required would need to complete part A health history.

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