Pre-Participation Medical History

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Revised 5.6.14
Loras College Athletic Training Department
Pre-Participation Medical History
Name: _________________________________ Social Security Number:_________________________
Date of Birth: _______________ Sex: _________________ Sport: ______________________________
Parent’s Address: _____________________________________________________________________
Parent’s Telephone: ____________________
EXPLAIN YES ANSWERS BELOW
YES NO
1. Have you ever been hospitalized?
____ ____
2. Have you ever had surgery?
____ ____
3. Are you presently taking any medications or pills?
____ ____
4. Do you have any allergies (medications, insects, or foods)?
____ ____
5. Have you ever passed out during or after exercise?
____ ____
6. Have you ever been dizzy during or after exercise?
____ ____
7. Have you ever had chest pain during or after exercise?
____ ____
8. Have you ever had high blood pressure?
____ ____
9. Have you ever had a positive sickle cell trait test?
____ ____
10. Have you ever been told that you have a heart murmur?
____ ____
11. Has anyone in your family died of heart problems or a sudden death before age 50?
____ ____
12. Do you have any skin problems (itching, rashes, acne)?
____ ____
13. Have you ever had a head injury?
____ ____
14. Have you ever been knocked out or unconscious?
____ ____
15. Have you ever had a seizure?
____ ____
16. Have you ever had a stinger, burner, or pinched nerve?
____ ____
17. Have you ever had heat or muscle cramps?
____ ____
18. Do you have trouble breathing, cough during or after activity, or have asthma?
____ ____
19. Do you use any special equipment (pads, braces, mouth or eye guards, etc.)?
____ ____
20. Have you had any problems with your eyes or vision?
____ ____
21. Have you ever suffered or been diagnosed with an eating disorder?
____ ____
22. Have you ever suffered or been diagnosed with depression?
____ ____
23. Do you wear glasses or contacts or protective eye wear?
____ ____
24. Have you ever sprained/strained, dislocated, fractured, broken or had repeated
swelling or other injuries of any bones or joints?
____ ____
__ Head __ Shoulder __Thigh __ Elbow __ Knee __ Chest __Hip
__ Forearm __ Shin/calf __ Back __ Wrist __ Hand __ Ankle/foot
25. Have you had any other medical problems (mono, diabetes, loss of paired organ, etc.)? ____ ____
26. Have you had a medical problem or injury since your last evaluation?
____ ____
27. When was your last tetanus shot? _____________________________
28. When was your last measles immunization? _____________________
Females Only:
29. When was your first menstrual period? ________________________
30. When was your last menstrual period? ________________________
31. When was your longest time between periods last year? ____________
Please explain any “yes” answers:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of Athlete: ____________________________________________________
Date_____________________________
Signature of Parent/Guardian (if student is under 18)__________________________________________ Date__________________

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