Virginia Sports Form

Virginia Sports Form - Part II

Form is required each school year MAY 1 of the current year through JUNE 30 of the succeeding year.
This form is only to be completed electronically if your child has had an annual well check in the preceding 12 months and the child has NOT had any significant changes to his/her medical history

**If the sports form is completed outside of well check there will be a $20 fee payable via the portal
Patient's name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
****In order to complete the sports questionnaire, you will need to have the date of the athlete's Tdap immunization. Please obtain the date from the portal prior to starting to fill out the form****
In the questions below, Explain all "YES" answers within the text box

General Medical History
1. Do you have any concerns that you would like to discuss with your provider?*
If yes, explain:
2. Has a provider ever denied or restricted your participation in sports for any reason?*
If yes, explain:
3. Do you have any ongoing medical conditions? If so, please identify:*

NoAsthmaAnemiaDiabetesInfectionsOther
4. Are you currently taking any medications or supplements on a daily basis?*
If yes, explain:
5. Do you have allergies to any medications?*
If yes, explain:
6. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?*
If yes, explain:
7. Have you ever spent the night in the hospital?*
If yes, explain:
8. Have you ever had surgery?*
If yes, explain:

Heart health Questions about you
9. Have you ever passed out or nearly passed out DURING or AFTER exercise?*
If yes, explain:
10. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*
If yes, explain:
11. Does your heart race, flutter in your chest or skip beats (irregular beats) during exercise?*
If yes, explain:
12. Has a doctor every ordered a test for your heart? For example, electrocardiography and echocardiography.*
If yes, explain:
13. Has a doctor ever told you that you have any heart problems, including:*

NoHigh blood pressureHigh cholesterolKawasaki DiseaseA heart murmurA heart infectionOther
14. Do you get light-headed or feel shorter of breath than your friends during exercise?*
If yes, explain:
15. Have you ever had a seizure?*
If yes, explain:

Heart Health Questions about your Family
16. Does anyone in your family have a heart problem?*
If yes, explain:
17. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car crash)?*
If yes, explain:
18. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia (CPVT)?*
If yes, explain:
19. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?*
If yes, explain:

Bone and Joint Questions
20. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?*
If yes, explain:
21. Do you currently have a bone, muscle or joint injury that bothers you?*
If yes, explain:

Medical Questions
22. Do you cough, wheeze or have difficulty breathing during or after exercise?*
If yes, explain:
23. Do you have asthma or use asthma medicine (inhaler, nebulizer)?*
If yes, explain:

Medical Questions Continued
24. Have you had mononucleosis (mono) within the last month?*
If yes, explain:
25. Are you missing a kidney, eye, testicle, spleen or other internal organ?*
If yes, explain:
26. Do you have groin or testicle pain or a painful bulge or hernia in the groin area?*
If yes, explain:
27. Have you ever become ill while exercising in the heat?*
If yes, explain:
28. When exercising in the heat, do you have severe muscle cramps?*
If yes, explain:
29. Do you have headaches with exercise?*
If yes, explain:
30. Have you ever had numbness, tingling or weakness in your arms or legs or been unable to move your arms or legs AFTER being hit or falling?*
If yes, explain:
31. Do you or does someone in your family have sickle cell trait or disease?*
If yes, explain:
32. Have you had any other blood disorders?*
If yes, explain:
33. Have you had a concussion or head injury that caused confusion, a prolonged headache or memory problems? *
If yes, explain:
34. Have you had or do you have any problems with your eyes or vision?*
If yes, explain:
35. Do you wear glasses or contacts?*
If yes, explain:
36. Do you wear protective eyewear like goggles or a face shield?*
If yes, explain:
37. Do you worry about your weight?*
If yes, explain:
38. Are you trying to or has anyone recommended that you gain or lose weight?*
If yes, explain:
39. Do you limit or carefully control what you eat?*
If yes, explain:
40. Have you ever had an eating disorder?*
If yes, explain:
41. Are you on a special diet or do you avoid certain types of foods or food groups?*
If yes, explain:
42. Allergies to food or stinging insects?*
If yes, explain:
43. Have you ever had a COVID-19 diagnosis? *
Date
44. What is the date of your last Tdap or Td (tetanus) immunization? (circle type first)*

TdapTd
Date of tetanus immunization*

MonthDayYear
Date

Females only
45. Have you ever had a menstrual period?
46. Age when you had your first menstrual period:
47. Number of periods in the last 12 months:
48. When was your most recent menstrual period?
List of medications and nutritional supplements you are currently taking here:
Additional comments:
Should be Empty:

Virginia Sports Form - Part II