Athletic Medical Evaluation Form - 2016-2017
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22016– 2017 ATHLETIC MEDICAL EVALUATION FORM
Personal History
Name ________________________________________________________ Sex _______ Age _______ DOB ____________
Grade ____________ Sport _________________________________ School _______________________________________
Personal Physician __________________________________________________ Telephone ___________________________
Address _______________________________________________________________________________________________
1. Have you ever had a pre-participation physical before?……………………………………………………….
Yes
No
Have you ever had surgery?……………………………………………………………………………………
Yes
No
2. Are you presently taking any medications or pills?……………………………………………………………
Yes
No
3. Do you have any allergies (medicine, bees or other stinging insects)?………………………………………...
Yes
No
4. Have you ever passed out during exercise?…………………………………………………………………….
Yes
No
Have you ever been dizzy during or after exercise?……………………………………………………………
Yes
No
Have you ever had chest pain during or after exercise?………………………………………………………..
Yes
No
Do you tire more quickly than your friends during exercise?………………………………………………….
Yes
No
Have you ever had high blood pressure?………………………………………………………………………
Yes
No
Have you ever been told that you have a heart murmur?………………………………………………………
Yes
No
Have you ever had a racing of your heart or skipped heartbeats?……………………………………………...
Yes
No
Has anyone in your family died of heart problems or a sudden death before age 50?…………………………
Yes
No
5. Do you have any skin problems (itching, rashes, acne) ?………………………………………………………
Yes
No
6. Have you ever had a head injury?………………………………………………………………………………
Yes
No
Have you ever been knocked unconscious?……………………………………………………………………
Yes
No
Have you ever had a seizure?…………………………………………………………………………………..
Yes
No
Have you ever had a stinger, burner, or a pinched nerve?……………………………………………………..
Yes
No
7. Have you ever had heat or muscle cramps?……………………………………………………………………
Yes
No
Have you ever been dizzy or passed out in the heat?…………………………………………………………..
Yes
No
8. Do you have trouble breathing or do you cough during or after activities?……………………………………
Yes
No
9. Do you use any special equipment (pads, braces, neck roll, mouth guard, eye guard) ?………………………
Yes
No
10. Have you had any problems with your eyes or vision?……………………………………………………….
Yes
No
Do you wear glasses or protective eye wear?…………………………………………………………………
Yes
No
11. Have you ever sprained/strained, dislocated, fractured, broken, or had repeated swelling of any bones or joints?
Head
Shoulder
Thigh
Neck
Elbow
Knee
Chest
Forearm
Shin/Calf
Foot
Back
Wrist/Hand
Ankle
Hip
12. Have you ever had any other specific medical problems (infectious mononucleosis, diabetes) ?……………
Yes
No
13. Have you had a medical problem since your last evaluation?………………………………………………...
Yes
No
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