Athletic Participation/parental Consent/physical Examination Form Page 2
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4PART II - - MEDICAL HISTORY
This form must be completed and signed, prior to the physical examination, for review by examining physical.
Explain “Yes” answers below with number of the question. Circle questions you don’t know the answers to.
MEDICAL HISTORY OF STUDENT & FAMILY
Yes
No
MEDICAL HISTORY OF STUDENT & FAMILY
Yes
No
1. Has a doctor ever denied or restricted your participation in
32. Do you have any rashes, pressure sores, or other skin
sports for any reason?
problems?
2. Do you have an ongoing medical condition (like diabetes or
33. Have you ever had herpes skin infection?
asthma)?
3. Are you currently taking any prescription or non
34. Have you ever had a head injury or concussion?
prescription (over the counter) medicines or pills?
4. Do you have allergies to medicines, pollens, foods or
35. Date of last head injury or concussion:
stinging insects?
Date:_____________________
5. Do you have prescriptions for use of epinephrine, adrenalin,
36. Have you ever been hit in the head and been confused or
inhaler, or other allergy medications?
lost your memory?
6. Have you ever passed out or nearly passed out during or
37. Have you ever been knocked unconscious?
after exercise?
7. Have you ever passed out or nearly passed out at any other
38. Have you ever had a seizure?
time?
8. Have you ever had discomfort, pain, or pressure in your
39. Do you have headaches with exercise?
chest during exercise?
9. Have you ever had to stop running after ¼ to ½ mile for
40. Have you ever had a numbness, tingling, or weakness in
chest pain or shortness of breath?
your arms or legs after being hit or falling?
10. Does your heart race or skip beats during exercise?
41. Have you ever been unable to move your arms or legs
after being hit or falling?
11. Has a doctor ever told you that you have (check all that apply):
42. When exercising in heat, do you have severe muscle
cramps or become ill?
High Blood Pressure
A heart murmur
43. Has the doctor told you that you or someone in your
High cholesterol
A heart infection
family has sickle cell trait or sickle cell disease?
12. Has a doctor ever ordered a test for your heart?
44. Have you had any other blood disorders or anemia?
13. Has anyone in your family died suddenly for no apparent
45. Have you had any problems with your eyes or vision?
reason?
14. Does anyone in your family have a heart problem?
46. Do you wear glasses or contact lenses?
15. Has any family member or relative died of heart problems or
47. Do you wear protective eyewear, such as goggles or a
sudden death before age 50? (This does not include
face shield?
accidental death)
16. Does anyone in your family have Marfan syndrome?
48. Are you happy with your weight?
17. Have you ever spent the night in a hospital?
49. Are you trying to gain or lose weight?
18. Have you ever had surgery?
50. Do you limit or carefully control what you eat?
19. Have you ever had an injury, like a sprain, muscle or
51. Has anyone recommended you change your weight or
ligament tear, or tendonitis that caused you to miss a
eating habits?
practice or game?
20. Have you had any broken or fractured bones or dislocated
52. Do you have any concerns that you would like to discuss
joints?
with a doctor?
21. Have you had a bone or joint injury that required x-rays,
53. What is the date of your last Tetanus immunization?
MRI, CT, surgery, injections, rehabilitation, physical
Date: ______________________________
therapy, a brace, a cast, or crutches?
22. Have you had a stress fracture?
FEMALES ONLY
54. Have you ever had a menstrual period?
23. Have you ever had an x-ray of your neck for atlanto-axial
55. Age when you had your first menstrual period? _________
instability? OR Have you ever been told that you have
disorder or any neck/spine problem?
24. Do you regularly use a brace or assistive device?
56. How many periods have you had in the last 12 months?
______________
25. Have you ever been diagnosed with asthma or other allergic
57. Do you take a calcium supplement?
disorders?
26. Do you cough, wheeze, or have difficulty breathing during
Explain “Yes” answers here:
or after exercise?
27. Is there anyone in your family who has asthma?
28. Have you ever used an inhaler or taken asthma medicine?
29. Were you born without or are you missing a kidney, an eye,
a testicle, or any other organ?
30. Have you had infectious mononucleosis (mono) within the
last three months?
31. Have you ever had mono or any illness lasting more than
two weeks?
Parent/Guardian Signature:
Athlete’s Signature:
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