Sports Physical Questionnaire

Name

Age

Date

School

Grade

Sports

Explain "YES" answers below. Select questions you don't know the answers to.

	Yes	No
1) Have you had a medical illness or injury since your last check up or sports physical?
2) Have you ever been hospitalized overnight?
3) Are you currently taking any prescription or non prescription medications or Inhalers?
4) Have you ever taken any supplements or vitamins to help you gain or lose weight or to improve your performance?
5) Do you have any allergies (pollen, medicine, fool, stinging insects)?
6) Have you ever had a rash or hives develop during or after exercise?
7) Have you ever passed out during or after exercise?
8) Have you ever been dizzy during or after exercise?
9) Have you ever had chest pain during or after exercise?
10) Do you get tired more quickly than your friends do during exercise?
11) Have you ever had a racing of your heart or skipped heartbeats?
12) Have you had high blood pressure or high cholesterol?
13) Have you ever been told you have a heart murmur?
14) Has any family member or relative died of heart problems or of sudden death before age 50?
15) Have you ever bad a severe viral infection within the last month (myocarditis, mononucleosis)?
16) Has a physician ever denied or restricted your participation in sports for any heart problems?
17) Do you have any current skin problems (itching, ((ashes, acne, warts, fungus, or blisters)?
18) Have you ever had a head injury or concussion?
19) Have you ever been knocked out, become unconscious or lost your memory?
20) Have you ever had a seizure?
21) Do you have frequent or severe headaches?
22) Have you ever bad numbness or tingling in your arms, hands, legs, or feet?
23) Have you ever had a stinger, burner, or pinched nerve?
24) Have you ever become ill from exercising in the heat?
25) Do you have cough, wheeze or have trouble breathing?
26. Do you hare asthma?
27) Do you have seasonal allergies that require medical treatment?
28) Do you use any special protective or corrective equipment or devices that aren't usually used for your sport or position (knee brace, special neck roll, foot orthotics, retainer, hearing aid)?
29) Have you had problems with your eyes or vision?
30) Do you wear glasses, contracts or protective eyewear?
31) Have you ever had a sprain, strain, or swelling after injury?
32) Have you broken or fractured any bones or dislocated any joints?
33) Do you want to weigh more or less than you do know?
34) Do you lose weight regularly to meet weight requirement for your sport?
35) Do you feel stressed out?

36) Have you had any other problems with pain or swelling in muscles, tendons, bones or joints?

YesNo

If yes, explain

Explain all 'Yes' answers here

When was your first menstrual period?

When was your last menstrual period?

How much time do you usually have from the start of one period to the start of next period?

How may periods have you had in the last year?

What was the longest time between periods in the last year?

I hereby state that, to the best of my knowledge, the answers to the above questions are complete and correct.

Signature of athlete

Signature of parent/guardian

Date

Sports Physical Questionnaire

Female only