Luther College Varsity Athletic Health-Status Questionnaire printable pdf download

LUTHER COLLEGE VARSITY ATHLETIC HEALTH-STATUS QUESTIONNAIRE

Participation History – To be completed by the Student Athlete

Students participating in intercollegiate athletics must have a complete physical examination including orthopedic screening, up-to-date immunizations, and

private health insurance information on file. A student-athlete who has sustained a significant injury or illness within the past 12 months must receive clearance

from a physician before resuming participation in a varsity sport.

Name __________________________________________________________ Date of Birth _____/______/______

Year in College: 1 2 3 4

ID Number _____________________________Sport _____________________________________________________________________________

Phone Number: (______) ________ - ____________

Luther Email: __________________________________________________________

Tetanus (must be within 10 years) _________________________

Are you CURRENTLY under the care of a physician for any chronic medical condition?

Yes

If yes, please indicate condition and treatment. ____________________________________________________________

Have you ever:

date

Passed out during exercise? ………..

Yes

No _____________

Had seizure/convulsions? ……………………

Yes

No __________

Had chest pain during exercise? ……

Yes

No _____________

Been dizzy during exercise? ………………….

Yes

No __________

Had a heart attack? ……………………….

Yes

No _____________

Had a head injury/concussion? ……………

Yes

No __________

Been told you have a heart murmur?

Yes

No _____________

Been knocked out? ………………………………..

Yes

No __________

Had racing heart/skipping beats?

Yes

No _____________

Had asthma or wheezing? ……..……….

Yes

No __________

Had heat exhaustion/heat stroke?

Yes

No _____________

Use an inhaler before you exercise?........

Yes

No __________

Been dizzy or passed out due to heat? …

Yes

No _____________

Have you been hospitalized or had a surgical operation?

Yes

No If yes, explain: __________________________________________________________

______________________________________________________________________________________________________________________________________

Has anyone in your family died from heart problems or died suddenly before age 55?

Yes

No If yes, explain:_____________________________________

_______________________________________________________________________________________________________________________________________

Do you:

Have weakness, pain, or swelling in any of the following?

Have high blood pressure? …………………………………………

yes

Y N

Tire more quickly than your friends during exercise? …

yes

Hand….

Arm….

Back..

Shin/Calf…

Smoke cigarettes? (number per day: ____) ………………..

yes

Wrist….

Shoulder

Hip..

Ankle……….

Use smokeless tobacco? ……………………………………………..

yes

Forearm

Neck….

Thigh

Foot…………

Have more than 2 alcoholic drinks per week? …………..

yes

Elbow

Chest

Knee..

Back………....

Have very irregular or absent periods? ……………………..

yes

Have diabetes? ………………………………………………………….

yes

Must you use special equipment for completion (pads, braces, neck roll, etc.)?

Wear eyeglasses/contact lenses/ protective eyewear?

yes

Yes

Are you missing one of any paired organ? (eye, kidney testicle)

Yes

If yes, please explain: _________________________________________________

Have you had mononucleosis recently?

Yes

No If yes, provide date: _____________________________________________________________________

Have you ever or are you currently being treated for any eating disorder?

Yes

No If Yes, explain:_______________________________________________

Are you now receiving or have you ever received treatment or counseling for mental health illness or substance abuse?

Yes

If yes, please explain: ________________________________________________________________________________________________________________

Sickle cell status:  positive  negative  unknown/waived

If Unknown/waived: I have completed the 2

Education sessions.

Yes

Are you presently taking any medications (birth control, prescriptions meds, vitamins, aspirin, etc.):

________________________________________________________________________________________________________________________

Have you or are you currently taking performance enhancement supplements (creatine, etc):

________________________________________________________________________________________________________________________

Please list any allergies you may have (medicine, bees, food, etc):

________________________________________________________________________________________________________________________

I, the undersigned herewith declare to the best of my knowledge, that the above questions have been answered truthfully and correctly and

Understand that I must refrain from practice or play during medical treatment until I am discharged from treatment or given a written permit by the

attending physician to resume participation.

Understand that having completed the pre-participation screening process does not necessarily mean I am physically qualified to engage in athletics, but

only that the examiner did not find a medical reason to disqualify me.

Understand that I cannot participate (practice or compete) until this form is signed by a Physician/Physician Assistant

Student Athletes Signature ________________________________________________________________________ Date __________________________________