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

Date

Gender

Cell Phone #

Format: (000) 000-0000.

I. SPECIFIC MEDICAL QUESTIONS

1. Have you ever had SURGERY?

If yes, when? Date

Date

Injury/Illness

2. Are you presently taking any prescribed medication(s), including inhalers, ADHD medications, etc?

If YES, please indicate name of drug, reason and usual dosage

II. ALLERGIES

1. Are you allergic to any medications?

(PLEASE LIST)

2. Are you allergic to any insect bites?

(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

Epilepsy

Chronic Fatigue

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

If yes, please explain

IV. CARDIOPULMONARY

1. Do you have asthma or ever been treated for an asthma attack?

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

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

If YES, specify date

Date

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

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

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

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

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

If yes, please explain:

3. Have you ever had a neck injury?

If yes, please explain:

4. Any other injuries, please list (shoulder, leg, etc.):

VII. OTHER

1. Do you wear orthotics in athletic shoes?

2. Ever suffer heat stroke or exhaustion?

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

Date

Parent Name

Parent Signature

Date