MEDICAL HISTORY QUESTIONNAIRE (Rams)

MEDICAL HISTORY QUESTIONNAIRE

Mount Douglas Rams Football Program
This Questionnaire is to be used by team trainers, coaches, and/or managers associated with the Mount Doug Rams Football Program.

Please include all relevant information, so student-athletes can effectively be assessed and treated in the case of injury or emergency.

Sport: HIGH SCHOOL FOOTBALL

This form must be filled out by Athlete & Parent/Guardian.
CONTACT INFORMATION
Athlete Name

First NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Athlete Date of Birth

MonthDayYear
Date
Athlete Health Care Card
IN CASE OF EMERGENCY NOTIFY:
Name (Contact Person #1)
Phone
Relationship
Name (Contact Person #2)
Phone
Relationship
Family Doctor Name
Family Doctor Phone
Family Dentist Name
Family Dentist Phone
HEALTH HISTORY:

(Please mark answers. You will be asked to explain any "YES" answers below)

	YES	NO
1. Have you ever been hospitalized?
2. Have you ever had surgery?
3.Are you presently taking any medications or pills?
4. Are you presently taking any vitamins or supplements?
5. Do you have any allergies (medicine, bees, or other stinging insects)?
6. Have you ever passed out during or after exercise?
7. Have you ever had chest pain during or after exercise?
8. Do you tire more quickly than your friends during exercise?
9. Have you ever had high blood pressure?
10. Have you ever been told that you have a heart murmur?
11. Have you ever had racing of your heart or skipped heartbeats?
12. Has anyone in your family died of heart problems or sudden death before age 50?
13. Do you have any skin problems (itching, rashes, acne)?
14. Have you ever had heat or muscle cramps?
15. Have you ever been dizzy or passed out in the heat?
16. Do you ever have trouble breathing or do you cough during or after activity?
17. Do you use any special equipment (pads, braces, neck rolls, mouth guard, eye guard, etc.)
18. Do you use any dental appliances?
19. Have you had any problems with your eyes or vision?
20. Do you wear glasses or contacts or protective eye wear?
21. Have you had any other medical problems (infectious mononucleosis, diabetes, etc.)?
22. Have you had a medical problem or injury since your last evaluation?
23. Have you had any unexplained weight change?

If you answered "YES" to any of the above questions, please provide details below:
When was your last tetanus shot?:
HEAD INJURIES / CONCUSSIONS:

Please answer the questions below related to head injuries & concussions.

	YES	NO
1. Have you ever had a seizure?
2. Have you ever had a head injury?
3. Have you ever had a concussion or been “knocked out,” had your “bell rung,” or been “dinged

If you answered "YES," please provide the number of concussions and details (including dates, activity at the time, length of concussion in minutes, and length of time before full return to activity).
Did you have any persistent issues associated with concussion?

Did you or have you experienced any of the following issues?

	YES	NO
Memory
Dizziness
Headaches

NECK INJURIES / BURNERS / STINGERS:

Please answer the questions below related to neck injuries, burners & stingers.

	YES	NO
1. Have you ever had a neck injury (i.e. strain, sprain, fracture, etc.)?
2. Have you ever had a stinger, burner or pinched nerve? (A burning or numb feeling in the shoulder or arm after a hit to the head, neck, or shoulder - AKA "brachial plexus stretch injury.")

If you answered "YES," please provide the number of times and details (including dates, activity at the time, length of time of sensation, and length of time strength changes persisted).
OTHER INJURIES

Please identify any areas that you have INJURED IN THE PAST and explain the injury below.

	YES	NO
Hand
Wrist
Forearm
Elbow
Arm
Shoulder
Neck
Chest
Back
Hip
Thigh
Knee
Shin / Calf
Ankle
Foot

If you answered "YES," please provide the details (including date of injury, type of injury, which side (left, right, both) and let us know if this injury is still a problem).
Do you have any incompletely healed injuries?

YESNO
If you answered "YES," which injuries? Please provide details.
Are you currently receiving treatment for any ongoing injuries?

YESNO
If "YES," please specify what type of treatment (i.e. physio, chiro, massage, etc.)
Do you participate in other organized, competitive sports?

YESNO
If "YES," please specify which sports:
CERTIFICATION

(Areas below are to be signed by Parent or Legal Guardian of Student/Athlete)
I certify that I have made a full and complete disclosure concerning and and all conditions, allergies, medications, injuries and head injury information of student / athlete.

I have answered completely and truthfully all questions.
Full Name
Insert Name of Parent or Legal Guardian of Student/Athlete
Date

MonthDayYear
Date
Signature of Parent or Legal Guardian

Clear
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

(Areas below are to be signed by Parent or Legal Guardian of Student/Athlete)
I _______________________(your name), the parent of legal guardian of
Insert Your Name / Name Parent or Legal Guardian
_______________________(athletes name), a member of the Mount Douglas Rams, Football Program
Insert Athlete's Name
Authorize the release of information with regards to my child's health and physical condition including injuries and their treatment to the team trainers, coaches and/or managers, only as it relates to my child's participation as a member of the above mentioned team.
Signature of Parent or Legal Guardian

Clear
Date

MonthDayYear
Date
Printed Name
Should be Empty:

MEDICAL HISTORY QUESTIONNAIRE

CONTACT INFORMATION

IN CASE OF EMERGENCY NOTIFY:

HEALTH HISTORY:

HEAD INJURIES / CONCUSSIONS:

NECK INJURIES / BURNERS / STINGERS:

OTHER INJURIES

CERTIFICATION

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION