Diabetes Management. Ancient Indian texts refer to diabetes. Modern diets and lifestyles are thought to contribute to the rising incidence of diabetes. …
SUNY FREDONIA ATHELTIC MEDICAL HISTORY QUESTIONNAIRE
Please return completed forms to: : Alicia M Simmonds; Assistant Athletic
Trainer; Fredonia State University; Dods Hall, Fredonia, NY 14063
TODAYS DATE ______________
Date of Birth:
NAME: Social Security :
Full Legal Name
Parent/Guardian Name: Parent Home
Phone:
Permanent/Home Address:
Street/Road/Apt City
State Zip
Local/College Address:
Street/Road/Apt/Dorm City
State Zip
Local/College/Cell Phone: Single:_____
Married: _____ Sports:
EMERGENCY NOTIFICATION: Name:
Relationship:
Address: Telephone: H C
W _____
City, State, Zip Code:
____________________________________________________________________________
____________________________________________________
FAMILY HISTORY:
If Living If Deceased
Age Health Age at Death Cause
Has any Relative ever had:
Circle WHO
Father: Cancer
Yes/No ________________________
Mother: Tuberculosis
Yes/No ________________________
Brother/Sister Diabetes
Yes/No ________________________
1 Heart Trouble
Yes/No ________________________
2 High Blood Pressure
Yes/No ________________________
3 Stroke
Yes/No ________________________
4 Epilepsy
Yes/No ________________________
Mental Illness
Yes/No ________________________
____________________________________________________________________________
___________________________________________________
PERSONAL HISTORY- PLEASE CIRCLE ALL ANSWERS AND PROVIDE INFORMATION WITH
ALL YES ANSWERS ATTACH DOCUMENTS WHERE NECESSARY
Do you take any medications for ADD or ADHD? No
Yes Which?
ILLNESSES: HAVE YOU EVER
HAD?
Measles No Yes Mononucleosis____________________No
Yes LIST ANY OTHER MEDICATIONS YOU
German Measles No Yes Colitis or other Bowel Disease
No Yes ARE TAKING AND REASON:
Mumps No Yes Hemorrhoids or any Rectal Disease
No Yes
Chicken Pox No Yes Nervous Breakdown No
Yes
Whopping Cough No Yes Food, Chemical or Drug Poisoning
No Yes
Scarlet Fever No Yes Asthma No
Yes
Scarlatina _________________ No Yes Heart Disease No
Yes
Diphtheria No Yes Hives or Eczema No Yes
Small Pox No Yes Frequent Infections or Boils
No Yes
Pneumonia No Yes Any other Disease No
Yes Weight Now_____ One-Year Ago_____
Pleurisy No Yes Which?
Rheumatic Fever No Yes ALLERGIES: ARE YOU ALLERGIC TO?
WOMEN ONLY - MENSTRUAL HISTORY
Arthritis or Rheumatism No Yes Penicillin No
Yes Regular? Yes____ No____ Varies____
Hepatitis A No Yes
Sulfa Drugs No Yes
Cycle___________ days From start to start
Hepatitis B No Yes Mycins No Yes
Any clots passed? Yes____ No____
Hepatitis C No Yes Merthiolate or Mercurochrome No
Yes Pain or Cramps? Yes____ No____
Hepatitis D No Yes Any Other Drug No Yes
Date of last period_________________
Gall Bladder Disease No Yes What?
Any discharge from vagina? Yes___ No___
Anemia No Yes Adhesive Tape No
Yes If so, color?_____________
Jaundice No Yes Cosmetics No Yes
Amount?_______________
Bladder Disease No Yes Tetanus Antitoxin or Serums
No Yes X-RAYS/MRIS: Have you ever had images
Anorexia or Bulimia No Yes Other Allergies No
Yes taken of the following:
Epilepsy No Yes What?
Electrocardiogram EKG No Yes
Migraine Headaches No Yes Codeine No
Yes Stomach or Colon No Yes
Tuberculosis No Yes Morphine
No
Yes Gall Bladder No Yes
Diabetes No Yes Tape Adherent No
Yes Back No Yes
Cancer No Yes Aspirin No
Yes Teeth No Yes
Seizures No Yes Other Antibiotics
No Yes Chest No Yes
Any bone or joint disease No Yes Which?
Extremities No Yes
Neuritis or neuralgia No Yes TRANSFUSIONS: HAVE YOU EVER HAD?
If yes, Describe
Gonorrhea or Syphilis No Yes Blood or Plasma Transfusion
No Yes
Any other STD No Yes Are you of African American or
Which? Mediterranean decent: No
Yes
Have you had a sickle cell test No Yes
DO YOU NOW HAVE OR HAVE YOU HAD WITHIN THE PAST YEAR ANY OF THE FOLLOWING
CONDITIONS/PROBLEMS?
IF YOU ANSWER YES, PLEASE ATTACH A SHEET DETAILING
Frequent or severe Headaches No Yes Fainting
Spells No Yes
Unconscious
Spells No Yes Blurred
Vision No Yes
Double Vision No Yes Spots Before
Eyes No Yes
Infected Eyes Pink Eye No Yes Pain
Behind Eyes No Yes
Any change in vision No Yes Discharge
from ears No Yes
Do you wear glasses No Yes
Decrease in hearing No Yes
Do you wear contact lenses No Yes
Recurrent nose bleeds No Yes
Hard Lenses or Soft Lenses Please circle
Sinus Trouble No Yes
Do you wear your contact lenses Strange
persistent odors No Yes
or glasses during competition No Yes
Enlarged Glands No Yes
Earaches No Yes Recurrent
sores in mouth No Yes
Ringing in ears No Yes Chest Pain
No Yes
Hearing problems
No Yes Pain in
arms No Yes
Recurrent head colds No Yes Chronic or
frequent cough No Yes
Hay Fever No Yes Wake up night short
of breath No Yes
Strange taste or loss in taste No Yes
Purple lips or fingers No Yes
Difficulty Swallowing No Yes Palpitations
or fluttering of heart No Yes
Recurrent sore throats No Yes High or
Low Blood Pressure No Yes
Soreness or bleeding of gums on brushing teeth No Yes
Swelling of hands, feet or ankles No Yes
Coughed up blood No Yes At
what time of day No Yes
Night Sweats No Yes Enlarged
veins in legs No Yes
Chronic or frequent cough on laying down No Yes
Difficulty starting urination No Yes
Recurrent heartburn No Yes Urinate more
or less
than before No Yes
Relieved by food or medication No Yes Nausea
or vomiting No Yes
Pain on urinating No Yes Loss of
urine on sneezing or coughing No Yes
Leg cramps on walking or at night No Yes
Joint Pains No Yes
Recurrent stomach pains No Yes Redness
or heat of any joint No Yes
Appetite: Good Fair Poor Muscle
spasms No Yes
Abdominal Cramps No Yes Trembling of
any extremity No Yes
Change in size, shape or texture of bowel Hot
flashes No Yes
Movement No Yes
Brittleness of finger/toe nails No Yes
Do you get up at night to urinate No Yes
Easy bruising No Yes
How many times do you urinate in 24 hours
Inability to stand cold or heat No Yes
Any blood in urine? No
Yes Growth in
neck or throat No Yes
Feeling of full bladder, but only a small
Tiredness without apparent reason No Yes
Amount of urination No Yes Change in
hair texture No Yes
Backaches No Yes Swelling of any
joints No Yes
Tingling or weakness of hands or feet No Yes
Any skin rash No Yes
Loss or change in sensation of hands or feet No Yes
Dryness of skin No Yes
Have you ever been treated for drug habits No Yes
Have you ever taken insulin or tablets for diabetes No Yes
Have you ever been treated for an overdose of medication ____No Yes
Have you ever taken hormone tablets or injections
No Yes
ORTHOPEDIC SECTION: Please provide details of any Yes answers in the
space provided and attach any physician documentation on surgeries when
necessary or Please request and have forwarded physicians reports on any
surgery or hospitalization you had within the PAST 5 YEARS
Have you ever been
knocked unconscious, Have you ever had a
burner/stinger No Yes Have you had a shoulder dislocation No
Yes
had a concussion or a head injury No Yes Do you have
low back pain No Yes Have you had shoulder separation No
Yes
How many Have you had an elbow dislocation
No Yes Have you had a shoulder subluxation No Yes
When Have you ever had an elbow fracture
No Yes Have you had Tennis Elbow No Yes
Have you had wrist dislocations No Yes Have you had a wrist
fracture No Yes Have you had hand/finger dislocations No Yes
Have you had hand/finger fractures No Yes Do you have
chronic hip/groin/ Have you had knee ligament tears No
Yes
Do you have locking sensations or IT band injuries
No Yes Do you have Plica Syndrome No Yes
giving out in your knees No Yes Do you
have Osgood Have you had a
patellar dislocation No Yes
Have you had knee meniscus tears No Yes Schlatters Disease
No
Yes Have you had a patellar subluxation No Yes
Have you had ankle sprains No Yes Have you had an ankle
fracture No Yes Have you had foot sprains No Yes
Do you have anterior compartment syndrome No Yes Do you have
recurrent shin splints No Yes Have you had foot fractures
No Yes
Have you had plantar fasciitis No Yes Do you wear orthotics
No Yes Have you had turf toe No Yes
If you answered yes to any questions, please provide details:
Source:somphyto.com
