UniUSA Medical History Form

Date of Completion

Date

Event

FISU Americas Sport

If you are Delegation Staff, scroll to the last option and select, "Delegation Staff".

World University Championships Sport

SWUG Sport

If you are Delegation Staff, scroll to the last option and select, "Delegation Staff".

WWUG Sport

If you are Delegation Staff, scroll to the last option and select, "Delegation Staff".

Name

First NameLast Name

Date of birth

Date

Sex

Age

Height

Weight

Personal medical insurance that covers you at the event is required. The local organizing committee will cover first response to injury, accident, or sickness, but ongoing coverage by your personal insurance is required.

Medical Insurance Company

Policy Number

Medicines: include over the counter and supplements

Write "N/A" if none

I have checked on GlobalDRO.com that none of my medications are prohibited in competition

Allergies or Sensitivities:

Write "N/A" if none

General Questions:

Rows	Yes	No
1. Has a doctor ever denied or restricted your participation in sports for any reason?
2. Have you ever spent the night in the hospital?
3. Have you ever had surgery?

4. Do you have any ongoing medical conditions? If so, please identify below:

Heart Health Questions About You:

Rows	Yes	No
5. Have you ever passed out or nearly passed out DURING or AFTER exercise?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
7. Does your heart ever race or skip beats during exercise?
8. Have you ever had a test for your heart? (ECG, echocardiogram) When? Why?
9. Do you get lightheaded or more short of breath than expected during exercise?
10. Have you ever had a seizure?

11. Has a doctor ever said that you have any of these heart problems?

Heart Health Questions About Your Family

Rows	Yes	No
12. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50?
13. 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?
14. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

Bone and Joint Questions:

Rows	Yes	No
15. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
16. Have you ever had broken/fractured bones, stress fractures, or dislocated joints?
17. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
18. Do you regularly use a brace, orthotics, or other assistive device?
19. Do any of your joints become painful, swollen, warm, or red?
20. Do you have a bone, muscle, or joint injury that bothers you?

Medical Questions:

Rows	Yes	No
21. Do you cough, wheeze, or have difficulty breathing during or after exercise?
22. Have you ever been told you have asthma or used an inhaler or taken asthma medicine?
23. Do you have sickle cell trait or disease?
24. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
25. Do you have a pain, bulge or hernia in the groin area?
26. Have you had infectious mononucleosis (mono) within the last 2 months?
27. Do you have any rashes, pressure sores, or other skin problems?
28. Have you had a herpes or MRSA skin infection?
29. Have you ever had a head injury or concussion?
30. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
31. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
32. Do you have headaches with exercise?
33. Have you ever become ill while exercising in the heat?
34. Do you get frequent muscle cramps when exercising?
35. Do you wear glasses or contact lenses?
36. Have you had any problems with your eyes or vision? Any eye injuries?
37. Do you worry about your weight?
38. Are you trying to or has anyone recommended that you gain or lose weight?
39. Are you on a special diet or do you avoid certain foods?
40. Have you ever had an eating disorder?
41. Do you have any concerns that you would like to discuss with a doctor?

42. Age when you had your first menstrual period?

43. Heavy or painful menses?

44. How many periods have you had in the last 12 months?

Explanation of "Yes" Answers:

Give number then description. Ex: #3: Concussion during a volleyball game on August 13, 2022.

Medical History Form

Explain "Yes" answers below.