Health History Form printable pdf download

HISTORY FORM

Pre‐Participation Physical Evaluation

(Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keep this form in the chart.)

Date of Exam ____________

Name ______________________________________________________________________________ Date of Birth __________

Sex ________ Age ___________ Year In College: ______________ Sport(s) ___________________________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are

currently taking. __________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Do you have any allergies?

Yes

If yes, please identify specific allergy below.

Medicines

Pollens

Food

Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS

YES

MEDICAL QUESTIONS

YES

1. Has a doctor ever denied or restricted your participation in sports

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?

for any reason?

2. Do you have any ongoing medical conditions? If so, please identify

27. Have you ever used an inhaler or taken asthma medicine?

below: Asthma Anemia Diabetes Infections

28. Is there anyone in your family who has asthma?

Other:___________________________________________________

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

29. Were you born without or are you missing a kidney, an eye, a testicle (males), your

spleen, or any other organ?

4. Have you ever had surgery?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

YES

31. Have you had infectious mononucleosis (mono) within the last month?

HEART HEALTH QUESTIONS ABOUT YOU

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

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

AFTER exercise?

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

33. Have you had a herpes or MRSA skin infection?

chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during

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

exercise?

8. Has a doctor ever told you that you have any heart problems? If

35. Have you ever had a hit or blow to the head that caused confusion, prolonged

so, check all that apply:

headache, or memory problems?

High blood pressure A heart murmur

36. Do you have a history of seizure disorder?

High cholesterol A heart infection

Kawasaki disease Other: ____________________________________

37. Do you have headaches with exercise?

9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,

38. Have you ever had numbness, tingling, or weakness in your arms or legs after being

Electrocardiogram).

hit or falling ?

10. Do you get lightheaded or feel more short of breath than

39. Have you ever been unable to move your arms or legs after being hit or falling?

expected during exercise?

11. Have you ever had an unexplained seizure?

40. Have you ever become ill while exercising in the heat?

12. Do you get more tired or short of breath more quickly than your friends during

41. Do you get frequent muscle cramps when exercising?

exercise?

42. Do you or someone in your family have sickle cell trait or disease?

HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

YES NO

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

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

unexplained sudden death before age 50 (including drowning, unexplained car

44. Have you had any eye injuries?

accident, or sudden infant death syndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome,

45. Do you wear glasses or contact lenses?

arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT

syndrome, Brugada syndrome, or catecholaminergic ,polymorphic ventricular

46. Do you wear protective eyewear, such as goggles or a face shield?

tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or implanted

47. Do you worry about your weight?

defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained seizures, or near

48. Are you trying to or has anyone recommended that you gain or lose weight?

drowning?

49. Are you on a special diet or do you avoid certain types of foods?

BONE AND JOINT QUESTIONS

YES NO

17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused

50. Have you ever had an eating disorder?

you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

51. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

19. Have you ever had an injury that required x‐rays, MRI, CT scan, injections, therapy,

a brace, a cast, or crutches?

52. Have you ever had a menstrual period?

20. Have you ever had a stress fracture?

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

21. Have you ever been told that you have or have you had an x‐ray for neck instability

or atlantoaxial instability? (Down syndrome or dwarfism)

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

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

Explain “yes” answers here:

23. Do you have a bone, muscle, or joint injury that bothers you?

___________________________________________________________________

24. Do any of your joints become painful, swollen, feel warm, or look red?

__________________________________________________________

25. Do you have any history of juvenile arthritis or connective tissue disease?

___________________________________Date________

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

Student‐Athlete Signature

Health History Form

Related Articles

Related forms

Related Categories