MEDICAL HISTORY:
Completed by Parent/Guardian or 18-Year-Old
Student Name
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor
Doctor's Phone
Date of Exam
Has a doctor ever denied or restricted your participation in sports for any reason?
*
Yes
No
Do you have any ongoing medical conditions? If so, please identify below:
Asthma
Anemia
Diabetes
Infections
Other (describe below):
If other, please describe:
Have you ever spent the night in the hospital or have you ever had surgery?
*
Yes
No
Do you have any concerns that you would like to discuss with the doctor?
*
Yes
No
HEART HEALTH QUESTIONS ABOUT YOU
*
Rows
Yes
No
Have you ever passed out or nearly passed out DURING or AFTER exercise?
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Has a doctor ordered a test for your heart? (example: ECG/EKG, echocardiogram)
Do you get lightheaded or feel more short of breath than expected during exercise?
Do you have a history of seizure disorder or had an unexplained seizure?
Do you get more tired or short of breath more quickly than your friends during exercise?
Has a doctor ever told you that you have any heart problems? Check all that apply
High blood pressure
Heart murmur
Heart infection
High cholesterol
Kawasaki disease
Other (describe below):
If other, please describe:
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
*
Rows
Yes
No
Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?
Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
BONE AND JOINT QUESTIONS
*
Rows
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?
Have you ever had any broken or fractured bones, dislocated joints, or stress fracture?
Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
Do you regularly use a brace, orthotics, or other assistive device?
Do you have a bone, muscle, or joint injury that bothers you?
Do any of your joints become painful, swollen, feel warm, or look red?
Do you have have any history of juvenile arthritis or connective tissue disease?
Have you ever had an x-ray for neck instability or atlantoaxial instability (Down syndrome or dwarfism)?
MEDICAL QUESTIONS
*
Rows
Yes
No
Do you cough, wheeze, or have difficulty breathing during or after exercise?
Have you ever used an inhaler or taken asthma medicine?
Is there anyone in your family who has asthma?
Were you born without, or missing a kidney, eye, testicle (males), spleen, or any other organ?
Do you have groin pain or a painful bulge or hernia in the groin area?
Have you had infectious mononucleosis (mono) within the last month?
Do you have any rashes, pressure sores, or other skin problems?
Have you had a herpes or MRSA skin infection?
Do you have headaches or get frequent muscle cramps when exercising?
Have you ever become ill while exercising in the heat?
Do you or someone in your family have sickle cell trait or disease?
Have you had any problems with your eyes or vision or any eye injuries?
Do you wear glasses or contact lenses?
Do you wear protective eyewear such as goggles or a face shield?
Are you missing any recommended vaccines?
Do you have any allergies?
Have you ever had a head injury or concussion?
Have you ever received a blow to the head that caused confusion, prolonged headache, or memory problems?
Have you ever had numbness, tingling, weakness, or inability to move your arms or legs after being hit or falling?
Have you ever had an eating disorder?
Do you worry about your weight?
Are you trying to or has anyone recommended that you gain or lose weight?
Are you on a special diet or do you avoid certain types of foods?
FEMALES ONLY (Optional) Have you ever had a menstrual period?
Yes
No
If yes, when was your most recent menstrual period? (Optional)
How old were you when you had your first menstrual period? (Optional)
How many periods have you had in the last 12 months? (Optional)
Please explain any "YES" answers:
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