Health History Update

Please answer the following questions:

SINCE YOUR CHILD'S LAST PHYSICAL...
Have any members of your family under age 50 had a “heart attack” or heart problem? *

Yes No
Have you been told you have a heart murmur, high blood pressure, extra heart beats or heart abnormality? *

Yes No
Have you "passed out, been diagnosed with a concussion or had a seizure? *

Yes No
Have you had a heat related illness? *

Yes No
Are you taking any new medications? *

Yes. No
Have you had an injury, illness, or condition that: required you to go the hospital or ER? *

Yes No
Have you had an injury, illness, or condition that required an operation? *

Yes No
Have you an injury, illness, or condition that lasted longer than a week? *

Yes No
If yes to the previous question, did you miss a game or practice? *

Yes No
Is this injury, illness or condition related to an allergy, asthma, hives, or medication?

Yes No
If you have answered “YES” to any of the questions listed above, please use this space to explain…(Please include details such as dates, who, what, where, and other detailed information as needed) :
Date: *

Month Day Year Hour Minutes AM/PM Option
Student Name (Please Print) *
Sport/Activity *
Grade *
Student Signature *
Parent Signature *
Should be Empty:

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