OBJECTIVE: This study evaluated the current preparticipation physical evaluation (PPE) administrative policies and cardiovascular screening content of all 50 states and Washington, DC.METHODS: PPE policies, documents, and forms from all 50 states and Washington, DC, were compared with the preparticipation physical evaluation-fourth edition (PPE-4) consensus recommendations. All electronic documents were publicly available and obtained from state interscholastic athletic associations.RESULTS: Fifty (98%) states required a PPE before participation. Most states (53%, n = 27) required a specific PPE form, whereas 24% (n = 12) of states recommended a specific form. Twenty-three states (45%) required or recommended use of the PPE-4 form or a modified version of it, and 27 states (53%) required or recommended use of outdated or unidentifiable forms. Ten states (20%) had not revised their PPE forms in .5 years. States permitted 9 different health care providers to administer PPEs. Only 22 states (43%) addressed all 12 of the PPE-4 personal and family history cardiovascular screening items, and 2 states (4%) addressed between 8 and 11 items. For the remaining 26 states, most (29%) addressed #3 screening items. CONCLUSIONS:Our results show that inconsistencies in PPE policies exist nationwide. Most states have been slow to adopt PPE-4 recommendations and do not adequately address the personal and family cardiovascular history questions. Findings suggest a need for PPE standardization nationwide and adoption of an electronic PPE process. This approach would enable creation of a national database and benefit the public by facilitating a more evidenced PPE.WHAT'S KNOWN ON THIS SUBJECT: Preparticipation physical evaluations (PPEs) are considered necessary for a high standard of care for US scholastic athletes. However, important questions remain regarding consistency of implementation and content of cardiovascular screening practices among states. WHAT THIS STUDY ADDS:Our results show that PPE policies are variable among US states, and adoption of current PPE-4 best practices is slow, demonstrating the need for nationwide PPE standardization.