Liberty Sports Medicine Pre-Participation Physical Evaluation Health Questionnaire
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2LIBERTY SPORTS MEDICINE PRE-PARTICIPATION PHYSICAL EVALUATION HEALTH
QUESTIONNAIRE
NAME:
_______________________
Sex: M/ F
AGE: ______
DOB:
____/____/_____
Answer all questions and explain all “YES” answers below:
Yes
No
1.
Do you have an ongoing chronic illness? (i.e. diabetes, ADHD, etc.)
2.
Have you ever had surgery or been hospitalized overnight?
3.
Are you currently taking any prescription or nonprescription medications? (i.e. inhalers, supplements or birth control)
4.
Have you ever taken supplements to lose or gain weight or improve your performance?
5.
Have you ever been told you have sickle cell or sickle cell trait?
6.
Do you have any allergies? (i.e. pollen, medicine, foods or stinging insects)
7.
Have you ever had a rash or hives develop during exercise?
8.
Have you ever been dizzy, passed out, or had chest pains during or after exercise?
9.
Do you get tired more quickly than your friends do during exercise?
10.
Have you ever had racing of your heart or skipped heart beats?
11.
Have you had high blood pressure or high cholesterol?
12.
Have you ever been told you have a heart murmur?
13.
Has any family member or relative died of heart problems or of sudden death before the age of 50?
14.
Have you had a severe viral infection such as mononucleosis or myocarditis within the last six months?
15.
Has a physician ever denied or restricted your participation in sports for any heart problems?
16.
Do you have any current skin problems? (i.e. itching, rash, warts, fungus, blisters, etc.)
17.
Have you ever had a head injury or concussion?
18.
Have you ever been knocked out, became unconscious or lost your memory?
19.
Have you ever had a seizure?
20.
Do you have frequent or severe headaches?
21.
Have you ever had numbness or tingling in your arms, hands, legs or feet?
22.
Have you ever had a stinger, burner or pinched nerve
23.
Have you ever become ill from exercise in the heat?
24.
Do you have asthma?
25.
Do you cough, wheeze or have trouble breathing during or after activity?
26.
Do you have seasonal allergies that require medical attention?
27.
Do you use any special protective or corrective equipment that are not currently used for your sport?
28.
Do you have any problems with your eyes or vision?
29.
Do you wear glasses, contacts, or protective eyewear?
30.
Have you ever had a sprain, strain, or swelling after injury?
31.
Have you ever fractured any bones or dislocated any joints?
32
Have you had any problems with pain or swelling in muscles, tendons, bones, or joints? Circle all that apply:
•Head / Neck / Back
•Shoulder / Upper Arm
•Ankle / Foot
•Knee
•Chest
•Elbow / Forearm
•Hand / Finger
•Hip / Thigh
• Shin / Calf
•Wrist
33.
Do you want to weigh more or less than you do right now?
Females: How many periods have you had in the last year? ____ When was your most recent menstrual period? ______
EXPLAIN ALL “YES” ANSWERS
HERE:______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Athlete _____________________________________
Date: ______________
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