Personal History
Name
________________________Sex_______Age
_______DOB __________
Grade_____Sport(s)___________________________
School_______________________
Personal Physician__________________Address__________Telephone_____
Have you every had a
preparticipation
physical before? ___ Yes ___ No
If yes, when/where ______________
| Please explain "Yes" answers below. |
|
No | ||||||||||
|
1.
|
Have you ever been hospitalized? | __ | __ | |||||||||
| Have you ever had surgery? | __ | __ | ||||||||||
|
2.
|
Are you presently taking any medications or pills? | __ | __ | |||||||||
|
3.
|
Do you have allergies (medicine, bees or other stinging insects? | __ | __ | |||||||||
|
4.
|
Have you every passed out during exercise? | __ | __ | |||||||||
| Have you ever been dizzy during or after exercise? | __ | __ | ||||||||||
| Have you ever had chest pain during exercise? | __ | __ | ||||||||||
| Do you tire more quickly than your friends during exercise? | __ | __ | ||||||||||
| Have you ever had high blood pressure? | __ | __ | ||||||||||
| Have you ever been told that you have a heart murmur? | __ | __ | ||||||||||
| Has anyone in your family died of heart problems or a sudden death before the age of 50? | __ | __ | ||||||||||
|
5.
|
Do you have any skin problems (itching, rashes, acne)? | __ | __ | |||||||||
|
6.
|
Have you ever had a head injury? | __ | __ | |||||||||
| Have you ever been knocked unconscious? | __ | __ | ||||||||||
| Have you ever had a seizure? | __ | __ | ||||||||||
| Have you ever had a stinger, burner or pinched nerve? | __ | __ | ||||||||||
|
7.
|
Have you ever had heat or muscle cramps? | __ | __ | |||||||||
| Have you ever been dizzy or passed out in the heat? | __ | __ | ||||||||||
|
8.
|
Do you have trouble breathing or do you cough during or after activities? | __ | __ | |||||||||
|
9.
|
Do you use any special equipment (pads, braces, neck role, mouth guard, eye guard)? | __ | __ | |||||||||
|
10.
|
Have you had any problems with your eyes or vision? | __ | __ | |||||||||
| Do you wear glasses or contacts or protective eye wear? | __ | __ | ||||||||||
| 11. | Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling of any bones or joints? | __ | __ | |||||||||
| _____ Head _____
_____
|
_____ Shoulder _____
_____
|
_____ Thigh _____
_____
|
_____ Neck _____
_____
|
_____ Elbow _____
_____
|
||||||||
|
12.
|
Have you ever had any other medical problem (infectious mononucleosis, diabetes)? | __ | __ | |||||||||
|
13.
|
Have you ever had a medical problem since your last evaluation? | __ | __ | |||||||||
|
14.
|
When was your last tetanus shot? | ____________ | ||||||||||
| When was your last measles shot? | ____________ | |||||||||||
|
15.
|
When was your first menstrual period? | ____________ | ||||||||||
| When was your last menstrual period? | ____________ | |||||||||||
| When was the longest time between your periods last year? | ____________ | |||||||||||
Please explain "yes" answers here:
I herby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of Athlete___________________________________
Signature of Parent/Guardian____________________________ Date _________
Signature of Coach________________________ School__________________
MED-01