Athletics Physical Form - Aylett Country Day School Page 2
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3AYLETT COUNTRY DAY SCHOOL
MEDICAL HISTORY
(This form must be completed and signed, prior to the physical examination, for review by examining practitioner.)
GENERAL MEDICAL HISTORY
Yes
No
MEDICAL QUESTIONS
Yes
No
1. Has a doctor ever denied or restricted your participation in
26. Do you cough, wheeze, or have difficulty breathing during
sports for any reason?
or after exercise?
2. Do you currently have an ongoing medical condition? If so,
27. Do you have asthma or use asthma medicine (inhaler,
Please identify:
Asthma
Anemia
Diabetes
nebulizer)
Infections
Other:
3. Have you ever spent the night in the hospital?
28. Were you born without or are you missing a kidney, an
eye, a testicle, spleen or any other organ?
29. Do you have groin pain or a painful bulge or hernia in the
4. Have you ever had surgery?
groin area?
30. Have you had mononucleosis (mono) within the last
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
month?
5. Have you ever passed out or nearly passed out DURING or
31. Do you have any rashes, pressure sores, or other skin
AFTER exercise?
problems?
6. Have you ever had discomfort, pain, or pressure in your
32. Have you ever had a herpes or MRSA skin infection?
chest during exercise?
7. Does your heart race or skip beats during exercise?
33. Are you currently taking any medication on daily basis?*
8. Has a doctor ever told you that you have (check all that
34. Have you ever had a head injury or concussion? If so, date
apply):
of last injury:
High Blood Pressure
A heart murmur High
cholesterol
A heart infection
Kawasaki disease
Other:
9. Has a doctor ever ordered a test for your heart? (For ex:
35. Have you ever had a numbness, tingling, or weakness in
ECG/EKG, echocardiogram)
your arms or legs after being hit or falling?
10. Do you get lightheaded or feel more short of breath than
36. Do you have headaches with exercise?
expected during exercise?
11. Have you ever had an unexplained seizure?
37. Have you ever been unable to move your arms or legs
after being hit or falling?
38. When exercising in heat, do you have severe muscle
HEART HEALTH QUESTIONS ABOUT YOUR
Yes
No
FAMILY
cramps or become ill?
12. Has any family member or relative died of heart problems
39. Has a doctor told you that you or someone in your family
or had an unexpected sudden death before age 50 (including
has sickle cell trait or sickle cell disease?
drowning, unexplained car accident, or sudden infant death
syndrome)?
13. Does anyone in your family have a heart problem?
40. Have you had any other blood disorders?
14. Does anyone in your family have a pacemaker or
41. Have you had any problems with your eyes or vision?
implanted defibrillator?
15. Does anyone in your family have Marfan syndrome,
42. Do you wear glasses or contact lenses?
cardiomyopathy, or Long Q-T?
16. Has anyone in your family had unexplained fainting,
43. Do you wear protective eyewear, such as goggles or a face
unexplained seizures, or near drowning?
shield?
BONE AND JOINT QUESTIONS
44. Do you worry about your weight?
Yes
No
17. Have you ever had an injury, like a sprain, muscle or
45. Are you trying to or has any professional recommended
ligament tear, or tendonitis that caused you to miss a practice
that you try to gain or lose weight?
or game?
18. Have you had any broken or fractured bones or dislocated
46. Do you limit or carefully control what you eat?
joints?
19. Have you had a bone or joint injury that required x-rays,
47. Do you have any concerns that you would like to discuss
MRI, CT, surgery, injections, rehabilitation, physical therapy,
with a doctor?
a brace, a cast, or crutches?
20. Have you ever had an x-ray of your neck for atlanto-axial
48. When is the date of your last Tdap or Td (tetanus)
instability? OR Have you ever been told that you have that
immunization? (Circle Type) Date: _____________________
disorder or any neck/spine problem?
21. Have you ever had a stress fracture of the bone?
FEMALES ONLY
22. Do you regularly use a brace or assistive device?
49. Have you ever had a menstrual period?
23. Do you currently have a bone, muscle, or joint injury that
50 Age when you had your first menstrual period? _______
bothers you?
24. Do any of your joints become painful, swollen, feel warm,
51. How many periods have you had in the last 12 months?
or look red?
________
25. Do you have a history of juvenile arthritis or connective
tissue disease?
EXPLAIN "YES" ANSWERS BELOW:
*List medications and nutritional supplements you are
#____ »
currently taking here:
#____ »
#____ »
#____ »
►►Parent/Guardian Signature:
Date:
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