Medical History
Date _______________ Name
__________________________________Sports_____________________
SS _______________ Date of Birth _____________ Sex ___________ Year
in School Fr So Jr Sr
PLEASE ANSWER THE FOLLOWING QUESTIONS IN AS MUCH DETAIL AS POSSIBLE
Please check the appropriate box Explain YES answers in space provided
Have you ever: Y N Comments
Been hospitalized or had any surgery?
_______________________________________
Broken a bone, or had a muscle injury?
_______________________________________
Been treated for a severe viral infection in
the last year? Ex Mono, myocarditis, etc
_______________________________________
Has anyone in your immediate family ever had:
Sudden death age less than 50?
_______________________________________
High blood pressure?
_______________________________________
Diabetes high blood sugar?
_______________________________________
Heart attack age less than 50?
_______________________________________
High cholesterol?
_______________________________________
Asthma?
_______________________________________
Have you ever had or do you now have:
Chest pain with or after exercise?
_______________________________________
Dizziness with or after exercise?
_______________________________________
Passed out with exercise?
_______________________________________
Racing of the heart/irregular rhythm?
_______________________________________
Heart murmur?
_______________________________________
High blood pressure?
_______________________________________
Diabetes high blood sugar?
_______________________________________
High cholesterol?
_______________________________________
Sickle cell anemia or sickle cell trait?
_______________________________________
Have you ever had or have now:
Cough/wheezing with exercise, asthma?
_______________________________________
Weakness, fatigue, or anemia?
_______________________________________
Use an inhaler?
_______________________________________
Have you had or do you now have:
Headaches or migraines?
_______________________________________
Hearing loss or perforated eardrum?
_______________________________________
Dental plate or orthodontic work?
_______________________________________
Impaired vision, wear glasses/contacts?
_______________________________________
Unequal pupils?
_______________________________________
Hernia?
_______________________________________
Numbness/tingling in any limbs
_______________________________________
Weight problem or recent weight gain/loss
__________________________________________
Date of last tetanus shot:
____________________________________________________________________________
List any current medications: prescription or nonprescription example:
acne, birth control, vitamins,
supplements
____________________________________________________________________________
______________________
List any allergies:
____________________________________________________________________________
_____
Have you ever had: Y N Comments
Concussion?
_______________________________________
Loss of consciousness?
_______________________________________
Convulsions seizures or epilepsy?
_______________________________________
Stress Fracture? Where, location, and
treatment: _____________
_______________________________________
Have you ever had a neck injury of any kind? If Yes, type of
injury? ____________________
Have you ever had any back injury/pain?
_______________________________________
If yes, location, dates
_______________________________________
Any special x-rays?
_______________________________________
Did you undergo rehabilitation?
_______________________________________
Have you ever sustained a shoulder injury?
_______________________________________
If yes, indicate type of injury, shoulder, dates
_______________________________________
Did you have surgery? If Yes,
when?___________________________
Did you undergo rehabilitation?
_______________________________________
Have you ever sustained a knee injury?
_______________________________________
If yes, indicate type of injury, knee and dates
_______________________________________
Did you have surgery? If Yes,
when?___________________________
Did you undergo rehabilitation?
_______________________________________
Have you ever sprained your ankle?
_______________________________________
If yes, indicate type of injury, ankle, and dates
_______________________________________
Did you have surgery? If Yes, when?
___________________________
Did you undergo rehabilitation?
_______________________________________
Have you ever worn a special brace, or had
modifications made in equipment worn? If Yes, indicate
reason____________________
Have you ever been treated for any
medical or
physical condition not mentioned?
______________________________________
Males:
Do you have a loss of function or absence of
testicles or any other related problem?
______________________________________
Females:
Do you have a menstrual cycle?
Age of onset of menstruation:
______________________________________
Have you had or do you now have menstrual
irregularities or absence of menses?
______________________________________
__________________________________________________________________________
______________________
I attest that the above information is correct and
complete to my knowledge
Athletes Signature
_______________________________________________________Date
___________________
Parent/Guardian Signature
________________________________________________Date ___________________
If athlete is under 18 years of age
Source:southwestortho.com
