Athletic Forms - Athletics

Student Athlete Health History Questionnaire

TO BE COMPLETED BY PARENT/GUARDIAN & STUDENT ATHLETE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Last Name: *

First Name: *

Middle Name: *

Gender: *

D.O.B.: *

/

Date of last physical exam: *

/

HISTORY

Have you had any illness/injury recently, or do you have an illness/injury now?: *

Yes

No

Have you ever been hospitalized overnight?: *

Yes

No

Do you have any chronic or recurrent illness or injury?: *

Yes

No

Have you ever had any illness lasting more than a week?: *

Yes

No

Have you had any surgery other than tonsillectomy?: *

Yes

No

Are you presently taking any medications or pills (including birth control, vitamin, aspirin, etc.)?: *

Yes

No

Have you ever passed out during exercise?: *

Yes

No

Do you have any organ missing other than tonsils (appendix, eye, kidney, testicle, etc.)?: *

Yes

No

Have you ever had chest pain or dizziness during or after exercise? : *

Yes

No

Have you ever had problems with your blood pressure or your heart?: *

Yes

No

Have any close relatives had heart problems, heart attacks or sudden death before they were age 50?: *

Yes

No

Do you have any skin problems (acne, itching, rashes, etc.)? : *

Yes

No

Have you ever had fainting, convulsions, seizures or sever dizziness?: *

Yes

No

Do you have frequent severe headaches?: *

Yes

No

Have you ever had a “stinger” or “burner” or “pinched nerve”?: *

Yes

No

Have you ever been “knocked” out or “passed out”?: *

Yes

No

Have you ever had a neck or head injury?: *

Yes

No

Have you ever had heat exhaustion, heat stroke, severe heat cramps or similar heat related problems?: *

Yes

No

Do you have asthma, trouble breathing or cough during or after exercise?: *

Yes

No

Do you use an inhaler for asthma?: *

Yes

No

Are you diabetic?: *

Yes

No

Do you administer insulin to yourself?: *

Yes

Do you wear eyeglasses, contact lenses or protective eye wear?: *

Yes

No

Have you had any problems with your eyes or vision?: *

Yes

No

Do you wear any dental appliance such as braces, bridge, plate, retainer?: *

Yes

No

Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injuries of any bones?: *

Yes

No

FEMALES: Have you any menstrual problems?:

Yes

No

Have you ever torn a tendon, ligament or muscle?: *

Yes

No

Do you use special equipment (brace,etc.)?: *

Yes

No

Do you drink alcohol?: *

Yes

No

If yes, if your alcohol consumption:

Mild

Moderate

Frequent

Are you presently using tobacco in any form?: *

Yes

No

Do you have a history of sickle-cell anemia in your family?:

Yes

No

Have you had a medical problem or injury within the last year?: *

Yes

No

Can you swim?: *

Yes

No

Do you currently use recreational or street drugs? : *

Yes

No

Have you ever given yourself street drugs with a needle?: *

Yes

No

Have you any medical concerns about participating in athletic activities?: *

Yes

No

Is stress a major problem for you?: *

Yes

No

Do you feel depressed?: *

Yes

No

Do you panic when stressed?: *

Yes

No

Do you have problems with eating or your appetite?: *

Yes

No

Do you cry frequently?: *

Yes

No

Have you ever attempted suicide?: *

Yes

No

Have you ever seriously thought about hurting yourself?: *

Yes

No

Have you ever seriously thought about hurting yourself?: *

Yes

No

Do you have trouble sleeping?: *

Yes

No

Have you ever been to a counselor?: *

Yes

No

Please explain any YES answer:

FAMILY HEALTH HISTORY

Father: *