BCS Student - Athlete Medical History

Department of Athletics and Sports

Student - Athlete Medical History Questionnaire
Full Name
First Last
Sport(s)
Year 20__ - ___
Date of Birth

MonthDayYear
Date
Gender
Cell Phone #
I. SPECIFIC MEDICAL QUESTIONS
1. Have you ever had SURGERY?

YesNo
If yes, when? Date

MonthDayYear
Date
Injury/Illness
2. Are you presently taking any prescribed medication(s), including inhalers, ADHD medications, etc?

YesNo
If YES, please indicate name of drug, reason and usual dosage
II. ALLERGIES
1. Are you allergic to any medications?

YesNo
(PLEASE LIST)
2. Are you allergic to any insect bites?

YesNo
(PLEASE LIST)
3. Do you have any other allergies? (PLEASE LIST)
III. ILLNESS
1. Have you suffered from or have been told by a physician you have had to do have the following:
Diabetes

YesNo
Epilepsy

YesNo
Chronic Fatigue

YesNo
2. Do you have any type of blood disorder (anemia, etc.)?

YesNo
If yes, please explain
IV. CARDIOPULMONARY
1. Do you have asthma or ever been treated for an asthma attack?

YesNo
If yes, do you carry or use an inhaler when you participate in sports?

YesNo
2. Have you ever been told you have a heart murmur or any other heart condition?

YesNo
If YES, specify date

MonthDayYear
Date
3. Have you ever been been held from competition for a heart condition?

YesNo
4. Have you ever experienced an "irregular" heartbeat, dizziness, or chest pain with exercise?

YesNo
5. Have you ever fainted, passed out, or blacked out during exercise?

YesNo
If yes, please explain
V. NOSE
Do you get nosebleeds? If yes, please explain:
VI. HEAD AND NECK
1. Have you ever suffered a concussion or head injury

YesNo
2. Do you suffer headaches (migraines or frequent)?

YesNo
If yes, please explain:
3. Have you ever had a neck injury?

YesNo
If yes, please explain:
4. Any other injuries, please list (shoulder, leg, etc.):
VII. OTHER
1. Do you wear orthotics in athletic shoes?

YesNo
2. Ever suffer heat stroke or exhaustion?

YesNo
3. Any additional information regarding any concerns or medical or personal, please let us know.
IMPORTANT NOTE: If you have been seen by a medical professional for any major or serious injuries or illnesses, PLEASE obtain and send copies of all office visit notes, any physical therapy notes, and/or tests done.

PLEASE make sure you have had your annual physical. Any delay in medical documentation may delay participation in athletics at Bethany Christian School.

I, understand, hereby acknowledge, affirm, and represent that all statements and answers on this questionnaire are true and accurate to the best of my knowledge.
Student-Athlete Name
Student Athlete Signature

Clear
Date

MonthDayYear
Date
Parent Name
Parent Signature

Clear
Date

MonthDayYear
Date
Should be Empty: