Recommended Sports Candidate Medical Questionnaire Template
ADVERTISEMENT
1
2MIAA RECOMMENDED SPORTS CANDIDATE MEDICAL QUESTIONNAIRE
PART A ~ HISTORY
DATE of EXAM
Student’s Na e
m
Sex
Age
Date of Birth
Grade
School
Sport(s)
Address
Tel
Physician
Tel
IN CASE OF AN EMERGENCY, CONTACT:
Name
Relationship _______________ Tel (H) ____________ (W) ________________
EXPLAIN “YES” ANSWERS BELOW. CIRCLE QUESTIONS YOU DON’T KNOW THE ANSWERS TO.
YES NO
YES NO
1.
Have you had a medical illness or injury
30.
Do you use any special protective or corrective
since your last check up or sports physical?
equipment or devices that aren’t usually used for
2.
Have you ever been hospitalized overnight?
your sport or position (for example, knee brace,
3.
Have you ever had surgery?
special neck roll, foot orthotics, retainer on your
4.
Do you have a missing or diseased paired organ?
teeth, hearing aid)?
5.
Are you currently taking any prescription or
31.
Have you had any problems with your eyes or vision?
nonprescription (over-the-counter) medications
32
Do you wear glasses, contacts, or protective eyewear?
or pills or using an inhaler?
33.
Have you ever had a sprain, strain, or swelling after
6.
Have you ever taken any supplements or vitamins
injury?
to help you gain or lose weight or improve your
34.
Have you broken or fractured any bones or dislocated
performance?
any joints?
7.
Do you have any allergies (for example, to pollen,
35.
Have you had any other problems with pain or
medicine, food, or stinging insects)?
swelling in muscles, tendons, bones, or joints?
8.
Have you ever had a rash or hives develop during
If yes, check appropriate box and explain below:
or after exercise?
Head
Elbow
Hip
9.
Have you ever passed out during or after exercise?
Neck
Forearm
Thigh
10.
Have you ever been dizzy during or after exercise?
Back
Wrist
Knee
11.
Have you ever had chest pain during or after exercise?
Chest
Hand
Shin/Calf
12.
Do you get tired more quickly than your friends do
Shoulder
Finger
Ankle
during exercise?
Upper Arm
Foot
13.
Have you ever had racing of your heart or skipped
36.
Do you want to weigh more or less than you do now?
heartbeat?
37.
Do you lose weight regularly to meet weight
14.
Have you had high blood pressure or high cholesterol?
requirements for your sport?
15.
Have you ever been told you have a heart murmur?
38.
Do you feel stressed out?
16.
Has any family member or relative died of heart
39.
Record the dates of your most recent immunizations
problems or of sudden death before age 50?
(shots) for:
17.
Have you had a severe viral infection (for example,
Tetanus ________________
Measles ________________
myocarditis or mononucleosis) within the last month?
Hepatitis B ______________
Chickenpox ______________
18.
Has a physician ever denied or restricted your
FEMALES ONLY:
participation in sports for any heart problems?
40.
When was your first menstrual period? __________________
19.
Do you have any current skin problems (for example,
41.
When was your most recent menstrual period? ___________
itching, rashes, acne, warts, fungus, or blisters)?
42.
How much time do you usually have from the start of one
20.
Have you ever had a head injury or concussion?
period to the start of another? _________________________
21.
Have you ever been knocked out, become
43.
How many periods have you had in the last year? _________
unconscious, or lost your memory?
44.
What was the longest time between periods in the last year?
22.
Have you ever had a seizure?
23.
Do you have frequent or severe headaches?
Explain “Yes” answers here: ___________________________________
24.
Have you ever had numbness or tingling in your arms,
__________________________________________________________
hands, legs, or feet?
__________________________________________________________
25.
Have you ever had a stinger, burner, or pinched nerve?
__________________________________________________________
26.
Have you ever become ill from exercising in the heat?
__________________________________________________________
27.
Do you cough, wheeze, or have trouble breathing
__________________________________________________________
during or after activity?
__________________________________________________________
28.
Do you have asthma?
__________________________________________________________
29.
Do you have seasonal allergies that require medical
__________________________________________________________
treatment?
I HEREBY STATE THAT TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO THE ABOVE QUESTIONS ARE COMPLETE AND CORRECT.
Signature of Athlete/Date _________________________________ Signature of Parent-Guardian/Date _____________________________________
~ over ~
Published: July 1, 2001
Revised 8/21/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life