Medical Evaluation Form: B History - Minot State University printable pdf download

Medical Evaluation

Form: B

HISTORY

Name _________________________________________Sex__________Age_________Date of Birth___________________

School________________________Grade/Year_____________________Sports____________________________________

Address________________________________________________Phone__________________________________________

Personal Physician_________________________Address______________________________________________________

Insurance________________________________________Policy Number_________________________________________

In case of emergency, contact

Name_________________________________Relationship______________Phone__________________________________

Explain “yes” answers below.

Yes

1. Has a doctor ever denied or restricted your

Yes

participation in school or work for any reason?

24. Do you cough, wheeze, or have difficulty breathing during or

after exercise?

2. Do you have an ongoing medical condition (like

25. Is there anyone in your family with asthma?

diabetes or asthma)?

26. Have you ever used an inhaler or taken asthma medication?

3. Are you currently taking any prescription or

27. Were you born without or are you missing a kidney, eye,

nonprescription medicines or pills?

testicle or any other organ?

4. Do you have allergies to medicines, pollens, foods, or

28. Have you had infectious mononucleosis (mono)?

stinging insects?

29. Do you have any rashes, pressure sores, or other skin problems?

5. Have you ever passed out or nearly passed out during

30. Have you had a herpes skin infection?

exercise?

31. Have you ever had a head injury or concussion?

6. Have you ever passed out or nearly passed out after

32. Have you been hit in the head and been confused or lost your

exercise?

memory?

7. Have you ever had discomfort, pain, or pressure in your

33. Have you ever had a seizure?

chest during exercise?

34. Do you have headaches with exercise?

8. Does your heart race or skip beats during exercise?

35. Have you ever had numbness, tingling, or weakness in your

9. Has a doctor ever told you that you have

arms or legs after being hit or falling?

(check all that apply):

36. Have you ever been unable to move your arms or legs after

__ High blood pressure

__ a heart murmur

being hit or falling?

__ High cholesterol

__ a heart infection

37. When exercising in the heat, do you have severe muscle

10. Has a doctor ever ordered a test for your heart?

cramps or become ill?

(EKG, echocardiogram)

38. Has a doctor told you that you or someone in your family

11. Has anyone in your family died for no apparent reason?

has sickle cell trait or disease?

12. Does anyone in your family have a heart problem?

39. Have you had any problems with your eyes or vision?

13. Has any family member or relative died of heart problems

40. Do you wear contact lenses or glasses?

or of sudden death before age 50?

41. Do you wear protective eyewear (goggles, face shield)?

14. Does anyone in your family have Marfan syndrome?

42. Are you happy with your weight?

15. Have you ever spent the night in the hospital?

43. Are you trying to lose or gain weight?

16. Have you ever had surgery?

44. Has anyone recommended you change weight or eating habits?

17. Have you ever had an injury (sprain, muscle tear, tendonitis)

46. Do you have any concerns you would like to discuss?

that caused you to miss practice or a game? If yes, circle below:

18. Have you had any broken or fractured bones or dislocated

FEMALES ONLY

joints? If yes, circle below:

47. Have you ever had a menstrual period?

19. Have you had a bone or joint injury that required x-rays,

48. How old were you when you had your first menstrual period? ___________

MRI, CT, surgery, injections, rehabilitation, physical therapy,

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

brace, cast, or crutches? If yes, circle below:

Head Neck Shoulder Arm Elbow Forearm Hand/Fingers

Explain “Yes” answers here:______________________________________

_______________________________________________________________

Chest Back Hip Thigh Knee Calf/Shin Ankle Foot/toes

_______________________________________________________________

20. Have you ever had a stress fracture?

_______________________________________________________________

21. Have you been told that you have or have you had an x-ray

_______________________________________________________________

for atlantoaxial (neck) instability?

_______________________________________________________________

22. Do you regularly use a brace or assistive device?

_______________________________________________________________

23. Has a doctor ever told you that you have asthma or allergies? __

_______________________________________________________________

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of Student ____________________________Signature of parent/guardian_____________________Date __________

Medical Evaluation Form: B History - Minot State University

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