Last Name First Name Date of Birth

Sport(s) 

Cell Telephone (AC) Home EMail Address
Emergency Contact Name Relationship to student
Telephone (AC)
Alternate Emergency Contact Relationship to student
Telephone (AC)

Insurance Carrier Type of Insurance
Address
Policy Number Group Number
Policy Holder's Name

GENERAL MEDICAL HISTORY

Are you presently taking any prescribed or over the counter medication? (including birth control pills, insulin, allergy shots/ pills, asthma inhalers, epilepsy medication, anti inflammatories, supplements, etc. If yes, please indicate the name, dosage and frequency of use.

Do you have an allergy to any of the following?

• Drug or medication  Select One Yes No
• Foods  Select One Yes No
• Insect or animals  Select One Yes No
• Plants, grasses, pollen  Select One Yes No
• Other  Select One Yes No

If yes, please indicate the type of allergy and any medications used for treatment.

Has a physician ever told you that you have/had any of the following problems?

• Mononucleosis  Select One Yes No
• Rubella  Select One Yes No
• Chicken pox  Select One Yes No
• Hearing Defect  Select One Yes No
• Stomach/intestinal ulcer  Select One Yes No
• Hernia  Select One Yes No
• Diabetes  Select One Yes No
• Sickle cell anemia  Select One Yes No
• Epilepsy  Select One Yes No
• Tumor, cyst, cancer  Select One Yes No
• Over-active thyroid  Select One Yes No
• Under-active thyroid  Select One Yes No
• Arthritis  Select One Yes No
• Marfan  Select One Yes No
• Heart abnormality  Select One Yes No
• Oral herpes (cold sores)  Select One Yes No
• Liver/spleen injury  Select One Yes No
• Hepatitis  Select One Yes No
• Bleeding/clotting disorder  Select One Yes No
• Anemia  Select One Yes No
• Blood clot/embolism  Select One Yes No
• Leukemia/blood disorder  Select One Yes No
• Blood in urine  Select One Yes No
• Kidney injury  Select One Yes No
• Frequent urinary infections  Select One Yes No
• Kidney disease  Select One Yes No
• Depression  Select One Yes No
• Other mental disorder  Select One Yes No

Have you ever had surgery to the following?

• Eyes  Select One Yes No
• Ears, nose, throat  Select One Yes No
• Heart  Select One Yes No
• Lungs  Select One Yes No
• Stomach, bowels, appendix  Select One Yes No
• Kidneys  Select One Yes No
• Liver/spleen  Select One Yes No
• Bone  Select One Yes No
• Muscle, ligament, tendon  Select One Yes No
• Joint  Select One Yes No

If yes, please indicate the date and reason for surgery.

Were you born with two normal eyes, ears, and kidneys? Select One Yes No
If no, please specify abnormality.

Do you presently have any rashes, fungal infections, or cold sores? Select One Yes No
If yes, please specify the skin problem.

Have you ever had heat exhaustion/heat stroke/sun stroke? Select One Yes No
If yes, please give detailed information.

During or after exercise have you ever

• Been dizzy or light-headed?  Select One Yes No
• Found it more difficult to breathe than normal?  Select One Yes No
• Passed out (fainted)?  Select One Yes No
• Had problems with coughing?  Select One Yes No
• Had chest pain, discomfort or tightness?  Select One Yes No

Have you ever been told that you have a heart murmur? Select One Yes No
If yes, have you ever been held out of sports due to the murmur? Select One Yes No
Have you ever had a racing of your heart, irregular, or skipped beats? Select One Yes No

Have you ever been told by a doctor that you had or have the following:

• High blood pressure?  Select One Yes No
• Pericarditis, myocarditis, endocarditis (infection of the heart)?   Select One Yes No
• Rheumatic fever?  Select One Yes No
• Other heart or vascular problems?  Select One Yes No

If yes, please give details.

Have you ever had any medical tests for your heart (EKG, echocardiogram)? Select One Yes No
If yes please specify the test, date and reason below.

Have you ever had any of the below listed conditions?

• Wheezing during or just after exercise  Select One Yes No
• Bronchitis  Select One Yes No
• Pneumothorax (collapsed lung)  Select One Yes No
• Tuberculosis  Select One Yes No
• Asthma  Select One Yes No

If the answer is yes to any of the above, do you carry an inhaler? Select One Yes No

Have you ever had a concussion with or without the loss of consciousness? Select One Yes No
If yes, how many times? Select One 1-2 3-4 4-5 5+
Have you ever been knocked unconscious? Select One Yes No
If yes, how many times? Select One 1-2 3-4 4-5 5+
Have you ever had any long term problems due to a head injury (memory loss, headaches, seizures, lack of concentration)?   Select One Yes No

Have you ever had any numbness, tingling or weakness in your:

• Shoulders/arms/hands  Select One Yes No
• Buttocks  Select One Yes No
• Legs/feet  Select One Yes No

If yes, are these symptoms currently present? Select One Yes No
Have you ever had a seizure? Select One Yes No
Do you experience migraine headaches? Select One Yes No
Have you ever had a serious eye injury? Select One Yes No
If yes, please specify.

Do you wear glasses or contact lenses? Select One Yes No
If yes, do you wear glasses or contacts when you train or compete? Select One Yes No
Have you had your eyes checked in the past 12 months? Select One Yes No
Do you have vision in both eyes? Select One Yes No
Are you legally blind in either of your eyes? Select One Yes No

Do you wear any of the following dental appliances?

• Permanent bridge?  Select One Yes No
• Full plate?  Select One Yes No
• Permanent crown?  Select One Yes No
• Braces?  Select One Yes No
• Removable partial?  Select One Yes No

Do you have any dead teeth? Select One Yes No
If yes, please give location.

Have you ever suffered from or are you currently suffering from Temporal Mandibular Joint Syndrome? Select One Yes No

MISCELLANEOUS HEALTH HISTORY

1. Weight 
2. Height 
3. Are you happy with your weight?  Select One Yes No
4. Has your weight fluctuated 15 or more pounds within the last year?  Select One Yes No
5. What would be your ideal weight? 
6. Are you happy with your current body build?  Select One Yes No
7. Do you avoid eating any of the following foods?
   • Meat  Select One Yes No
   • Bread/grains  Select One Yes No
   • Vegetables/fruits  Select One Yes No
   • Fats  Select One Yes No
   • Dairy products  Select One Yes No
8. Have you ever been diagnosed with an eating disorder?  Select One Yes No
9. Have you ever tried to control your weight with any of the following?
   • Fasting  Select One Yes No
   • Diuretics  Select One Yes No
   • Vomiting  Select One Yes No
   • Diet pills  Select One Yes No
   • Laxatives  Select One Yes No
   • Excessive exercise  Select One Yes No
10. Do you have concerns about the eating habits of any teammates?  Select One Yes No

WOMEN ONLY, MEN SKIP TO NEXT SECTION

1. When was your most recent menstrual period?  
2. In the past 12 months:

• Have you had trouble with heavy menstrual bleeding?  Select One Yes No
•  Have you had bleeding between periods?  Select One Yes No
• Have you had menstrual cramps or pain which affection your school or athletic performance? Select One Yes No                                                   
• How many periods have you had?  
• What was the longest time between periods? 
• On average, how long has each period lasted? 

3. Are you presently taking any female hormones (estrogen, progesterone, birth control pills) for the purpose of regulating your periods?  Select One Yes No                                    
If yes, when was your last pelvic exam/ PAP smear ?  

Has your pelvic exam/ PAP smear ever been abnormal?  Select One Yes No
4. Would you like to discuss with the medical staff any gynecological problems?   Select One Yes No
5. Are you currently restricting your food intake? Select One Yes No

MEN ONLY, WOMEN GO BACK TO PREVIOUS SECTION
1. Were you born with two normal testicles?   Select One Yes No                                       
2. Have you ever had surgery to remove or repair a testicle?  Select One Yes No

ORTHOPEDIC HISTORY

Have you had within the past 2 years or do you currently have an injury or problem with the following?

If you answered that you currently have present medical conditions, please specify date of injury, right/ left, treatment being received, etc:

 In the past 3 years, have you been treated for a serious injury/ illness not mentioned above? Select One Yes No

If yes, please specify.

 The undersigned, herewith,

1. Understands that he/ she must refrain from practice or play while ill or injured, whether or not receiving medical treatment, and during medical treatment until he/ she is discharged from treatment or is given permission by the clinical practitioner to restart participation despite continuing treatment.
2. Understands that having passed the physical examination does not necessarily mean that he/ she is physically qualified to engage in athletics but only that the examiner did not find a medical reason to disqualify him/ her at the time of said exam.
3. Certifies that the answers to all of the questions are correct and true

STUDENT-ATHLETE SIGNATURE

DATE

SIGN BY USING THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER