Health History Update Questionnaire Form - New Jersey Department Of Education
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State of New er
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EPARTMENT OF
DUCATION
HEALTH HISTORY UPDATE QUESTIONNAIRE
Name of School __________________________________________________________________________________
To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose
physical examination was completed more than 90 days prior to the first day of official practice shall provide a
health history update questionnaire completed and signed by the student’s parent or guardian.
Student _________________________________________________________________ Age______ Grade ________
Date of Last Physical Examination_________________________________ Sport______________________________
Since the last pre-participation physical examination, has your son/daughter:
1. Been medically advised not to participate in a sport?
Yes____ No____
If yes, describe in detail __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Sustained a concussion, been unconscious or lost memory from a blow to the head? Yes____ No____
If yes, explain in detail ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Broken a bone or sprained/strained/dislocated any muscle or joints?
Yes____ No____
If yes, describe in detail __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Fainted or “blacked out?”
Yes____ No____
If yes, was this during or immediately after exercise?___________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Experienced chest pains, shortness of breath or “racing heart?”
Yes____ No____
If yes, explain__________________________________________________________________________________
_____________________________________________________________________________________________
6. Has there been a recent history of fatigue and unusual tiredness?
Yes____ No____
7. Been hospitalized or had to go to the emergency room?
Yes____ No____
If yes, explain in detail ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Since the last physical examination, has there been a sudden death in the family or has any member of the family
under age 50 had a heart attack or “heart trouble?”
Yes____
9. Started or stopped taking any over-the-counter or prescribed medications?
Yes____ No____
If yes, name of medication(s)______________________________________________________________________
_____________________________________________________________________________________________
Date:________________________ Signature of parent/guardian ___________________________________________
E14-00284
PLEASE RETURN COMPLETED FROM TO THE SCHOOL TRAINER’S OFFICE
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