Report Of Medical History - Gable Health And Counseling Center/department Of Sports Medicine
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1
2To the Student:
Gable Health and Counseling Center/Department of Sports Medicine
This information is
th
13
& Bern Streets, P.O. Box 15234 • Reading, PA 19612-5234
strictly for the use of the
Health Center and will
(610) 921-7532 • FAX (610) 921-7590
not be revealed to anyone
without your knowledge
and consent.
REPORT OF MEDICAL HISTORY
PLEASE COMPLETE THIS BEFORE GOING TO YOUR PHYSICIAN FOR EXAMINATION
Sex: M
F
___________________________________________________________________________________________________________________
Last Name
First Name
Middle
Date of Birth
Class Entering
Marital Status
___________________________________________________________________________________________________________________
Home Address
City
State
Zip Code
Cell Phone Number
Home Telephone Number
___________________________________________________________________________________________________________________
Mother/Guardian: Name
Address
City
State
Zip Code
Cell Phone Number
Home Telephone Number
___________________________________________________________________________________________________________________
Father/Guardian: Name
Address
City
State
Zip Code
Cell Phone Number
Home Telephone Number
___________________________________________________________________________________________________________________
Mother/Guardian Employer and Phone Number:
Father/Guardian Employer and Phone Number
___________________________________________________________________________________________________________________
Transfer Students: List names and addresses of colleges you have attended.
Will you be participating in Albright Athletics: _________________________ If so, which sports?_________________________
FAMILY HISTORY
Have any of your relatives ever had any of the following?
Age of
State of
Age
Occupation
Cause of Death
Health
Death
Yes
No
Relationship
Father
Tuberculosis
Mother
Diabetes
Kidney Disease
Brothers
Heart Disease
Arthritis
Stomach Disease
Sisters
Asthma, Hay Fever
Epilepsy, Convulsions
PERSONAL HISTORY
(Please answer all questions. Comment on all positive answers in space below or on separate sheet.)
HAVE YOU HAD?
Yes
No
Yes
No
Yes
No
Yes
No
Scarlet Fever
Insomnia
Pain/Pressure in Chest
Gallbladder trouble
or Gallstones
Chicken Pox
Frequent Anxiety
Malaria
Worry or Nervousness
Palpitations (Heart)
Recurrent Diarrhea
Sinusitis
Depression
Hernia
High or Low Blood
Pressure
Recurrent Colds
Recurrent Headache
Recent Gain or Loss
of Weight
Chronic Cough
Rheumatic Fever or
Head Injury
Heart Murmur
Dental Problems
Dizziness, Fainting
Eye trouble
Hay Fever, Asthma
Injury of Joints
Weakness, Paralysis
Ear, Nose, or Throat
ADD/Hyperactivity
Sickle Cell
Sexually Transmitted
trouble
Disorder
Disease/Trait
Infection
Rheumatologic
Albumin/Sugar in
Shortness of Breath
Tuberculosis
Diseases
Urine
Orthopedic Surgeries
Allergy
Back Problems
Frequent Urination
Surgery
Penicillin
Tumor, Cancer, Cyst
FEMALES ONLY
Appendectomy
Sulfonamides
Jaundice
Currently Pregnant?
Tonsillectomy
Serum
Irregular Periods
Stomach or Intestinal
Hernia Repair
Foods (which)
Severe Cramps
trouble
Other:
Other:
Excessive Flow
Yes
No
USE ADDITIONAL SHEET FOR REMARKS OR
A. Has your physical activity been restricted during the past five years?
(give reasons and durations)
ADDITIONAL INFORMATION
B. Have you had difficulty with school, studies or teachers? (give details)
C. Have you received treatment or counseling for a nervous condition,
I understand that any special physical condition or circumstance that
personality or character disorder, or emotional problem? (give details)
may arise may necessitate the infirmary personnel to share confidential
D. Have you had any illness or injury or been hospitalized other than
information with local medical personnel to insure appropriate medical
already noted? (give details)
care.
E. Have you consulted or been treated by clinics, physicians, healers or
other practitioners within the past five years? (other than checkups)
________________________________________________
F. Have you been rejected for or discharged from military service because
Student’s Signature
of physical, emotional or other reasons? (if so, give details)
G. Concussion History?
Date of Concussion(s)
________________________________________________
________________
If so, how many?
How long did you miss your sport?
Physician’s Signature (acknowledging review)
Date
H. Is there loss or serious impaired function of any paired organ?
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