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English (US)
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Name of Student
*
Student Birth date
*
-
Month
-
Day
Year
Date
Student Phone Number
Please enter a valid phone number.
Student Address
Gender
*
Please Select
Male
Female
Age (in years)
School year
*
Please Select
23-24
24-25
25-26
26-27
27-28
28-29
29-30
30-31
21-32
32-33
Grade in School
Please Select
9th
10th
11th
12th
School
*
Please Select
Deseret Peak HS
Grantsville HS
Stansbury HS
Tooele HS
Sport(s) you plan to participate in
Is the student covered by health/accident insurance?
*
Yes
No
Name of health insurance provider
*
If no insurance provider, explain
List prescriptions, over-the-counter medications and supplements that you are currently taking
*
If not taking any medications, enter "NONE"
Do you have any allergies?
*
Yes
No
What type of allergies do you have?
Medications
Pollens
Food
Stinging Insects
List Medication Allergies
List Pollen Allergies
List Food Allergies
List Insect Allergies
Has a doctor ever denied or restricted your participation in sports for any reason?
*
Yes
No
Do you have any ongoing medical conditions?
*
Yes
No
Please specify
Asthma
Anemia
Diabetes
Infections
Other
Have you ever spent the night in the hospital?
*
Yes
No
Have you ever had surgery?
*
Yes
No
Have you ever passed out or nearly passed out DURING or AFTER exercise?
*
Yes
No
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
*
Yes
No
Does your heart ever race or skip beats (irregular beats) during exercise?
*
Yes
No
Has a doctor ever told you that you have any heart problems?
*
Yes
No
Please specify
High Blood Pressure
High Cholesterol
Kawasaki Disease
Heart Murmur
A Heart Infection
Other
Has a doctor ever ordered a test for your heart? (e.g. ECG/EKG,Echocardiogram)?
*
Yes
No
Do you get light headed or feel more short of breath than expected during exercise?
*
Yes
No
Have you ever had an unexplained seizure?
*
Yes
No
Do you get more tired or short of breath more quickly than your friends during exercise?
*
Yes
No
Has any family member or relative died of a heart problem or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?
*
Yes
No
Does anyone in your family have hypertrophic cardiomyopathy, Long QT syndrome, Short QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia?
*
Yes
No
Does anyone in your family have a heart problem, pacemaker, or implanted Defibrillator?
*
Yes
No
Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
*
Yes
No
Have you ever had an injury to a bone, muscle , ligament or tendon that caused you to miss a practice or a game?
*
Yes
No
Have you ever had any broken, fractured or dislocated bones?
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Yes
No
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches?
*
Yes
No
Have you ever had a stress fracture?
*
Yes
No
Have you ever been told that you have or have you had an x-ray for a neck instability or atlantoaxial instability (down syndrome or dwarfism)?
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Yes
No
Do you regularly use a brace, orthotics, or other assistive devices?
*
Yes
No
Do you have a bone, muscle, or joint injury that bothers you?
*
Yes
No
Do any of your joints become painful, swollen, feel warm or look red?
*
Yes
No
Do you have any history of juvenile arthritis, or connective tissue disease?
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Yes
No
Have you had any problems with pain, swelling, fracture, sprain, strain, or dislocation in any joint?
*
Yes
No
Please specify
Head
Neck
Back
Shoulder
Arm
Elbow
Finger
Wrist
Hand
Shin/Calf
Thigh
Knee
Hip
Ankle
Foot
Head (explain)
Neck (explain)
Back (explain)
Shoulder (explain)
Arm (explain)
Elbow (explain)
Finger (explain)
Wrist (explain)
Hand (explain)
Shin/Calf (explain)
Thigh (explain)
Knee (explain)
Hip (explain)
Ankle (explain)
Foot (explain)
Do you cough, wheeze or have difficulty breathing during or after exercise?
*
Yes
No
Have you ever used an inhaler or taken asthma medication?
*
Yes
No
Is there anyone in your family who has asthma?
*
Yes
No
We’re you born without it are you missing a kidney, an eye, a testicle (males), your spleen or any other organ?
*
Yes
No
Do you have groin pain or a painful bulge or hernia in the groin area?
*
Yes
No
Have you had infectious mononucleosis (mono) within the last month?
*
Yes
No
Do you have any rashes, pressure sores, or other skin problems?
*
Yes
No
Have you had a herpes or MRSA skin infection?
*
Yes
No
Do you have a history of seizure disorder?
*
Yes
No
Have you had any problems with your eyes or vision?
*
Yes
No
Have you had any eye injuries?
*
Yes
No
Do you wear glasses or contact lenses?
*
Yes
No
Do you wear protective eyewear such as goggles, or a face shield?
*
Yes
No
Do you worry about your weight?
*
Yes
No
Are you trying to or has anyone recommended that you try to lose or gain weight?
*
Yes
No
Are you on a special diet or do you avoid certain types of foods?
*
Yes
No
Have you ever had an eating disorder?
*
Yes
No
Have you ever become ill while exercising in the heat?
*
Yes
No
Do you get frequent muscle cramps when exercising?
*
Yes
No
Do you or someone in your family have sickle cell trait or disease?
*
Yes
No
Do you have headaches with exercise?
*
Yes
No
Have you ever had a head injury or concussion?
*
Yes
No
Have you ever had a hit or blow to the head that caused confusion, prolonged headache or memory problems?
*
Yes
No
Have you ever had numbness, tingling or weakness in your arms or legs after being hit or falling?
*
Yes
No
Have you ever been unable to move your arms or legs after being hit or falling?
*
Yes
No
At what age did you have your first menstrual period?
*
When was your most recent Menstrual period?
*
How much time do you usually have from the start of one menstrual period to the start of the next one?
*
How many periods have you had in the last year?
*
What was the longest time between periods in the last year?
*
Parent or Guardian Name
*
Parent or Guardian Signature
*
Signature of Student
*
Date Signed
-
Month
-
Day
Year
Physician's Office
Physician's Address
Physician's Phone Number
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