Diabetes (high sugar in blood or urine)? Tendency to bleed or bruise easily? Diabetes (high sugar in blood or urine)? Heart trouble? High blood pressure? …
Medical History Form
Students Name: SS: -
-
Date of Birth: Sex: Male Female
Family Doctor Family Dentist
or Clinic:
or Clinic:
1
YES NO
2 Has anyone in your family under age 50 died
suddenly from causes other than accident?
Explain:
3 Have you had or do you now have:
Brain concussion head injury?
Tendency to lose consciousness faint?
Skull fracture?
Convulsions or epilepsy?
Neck injury?
3 Have you had or do you now have:
Brain concussion head injury?
Tendency to lose consciousness faint?
Temporary loss of vision?
4 Do you NOW or within the past 12 months
have: Hernia?
Kidney problems?
5 Do you NOW or within the past 12 months
have: Bone fracture date?
6 Have you had or do you now have:
Diabetes high sugar in blood or urine?
Tendency to bleed or bruise
easily?
7 Have you had or do you now have:
Heart trouble or mummer?
High blood pressure?
Persistent cough?
Chest pain with exercise:
Dizziness or faintness with exercise?
8 Do you wish to discuss an emotional problem
with a doctor?
9 Have you ever been told to give up sports for
health problems?
Date of Last Tetanus Booster
YES NO
10 During the past 12 months:
a was he/she hospitalized?
b have illnesses lasting more than 1 week
11 Do you know of any reason why there should be limits
placed on his/her participation in any sport?
12 Is he/she missing any paired organ eyes, kidney,
testicle, etc?
13 Do you want to talk to a doctor about a health
problem or an injury?
14 During the past 12 months did he/she have injuries
requiring medical attention?
Explain:
15 Has anyone in your close family ever had:
Diabetes high sugar in blood or urine?
Heart trouble?
High blood pressure?
16 Have you had or do you now have:
Hearing loss?
Perforated ear drum?
17 Have you had or do you now have:
Asthma wheezing? If yes, do you
actively wheeze when exercising?
Do you take
medications for wheezing?
Bee sting reactions allergy?
If yes, do you require injectable medications?
Reaction to medications allergy?
List:
18 Do you:
Smoke?
Take any medications regularly? If yes,
please list:
Take any medications for emergency use?
If yes, please list:
I hereby certify that he above form has been reviewed and answered
correctly I also understand that the athletic screening physical to be
performed on me is only a screening physical It does not replace a
complete physical that could be performed by family physician
Signature of Patient: ____________________________________________ Date:
_____________________________
Source:cisco.cc.tx.us
