Please explain yes’ answers Circle your choice. 1. Have you ever been hospitalized? your heart, blood pressure, diabetes, or seizures? …
LAWRENCE UNIVERSITY
ATHLETIC MEDICAL QUESTIONNAIRE
Please print clearly
Name __________________________________________ Date
_________________________
Sport __________________________________________ DOB
_____/_____/________
Class Year Fr ____ So ____ Jr ____ Sr ____ LU
ID______________________
School address _____________________________ Home Address
__________________________
_____________________________
__________________________
Cell phone____________________ Home phone
_________________________
Please explain yes answers Circle
your choice
1 Have you ever been hospitalized?____________________________________
Yes No
2 Have you ever had surgery? ________________________________________
Yes No
3 Are you presently taking any over-the-counter medications or
supplements? Yes No
____________________________________________________
Are you presently taking any prescription medications?
__________________ Yes No
4 Do you have any
allergies medicine, food, etc
________________________ Yes No
_______________________________________________________________
5 Have you ever passed out or nearly fainted during exercise?
Yes No
Have you ever had chest discomfort or chest pain during exercise?
Yes No
Do you tire quicker than your friends during exercise?
Yes No
Have you ever been told you have a heart murmur?
Yes No
Have you ever had high blood pressure?
Yes No
Have you ever had racing of your heart or skipped beats?
Yes No
Has anyone in your family died of heart problems or sudden death
before age 50? Yes No
Have you been told you have sickle-cell anemia?
Yes No
Do you have a close relative under age 50 with disability from heart
disease? Yes No
Do you or any of your family have knowledge of cardiac conditions?
Marfans syndrome, cardiomyopathy, long QT syndrome
Yes No
Are you presently taking any prescription medications on a regular
basis for Yes No
your heart, blood pressure, diabetes, or seizures?
_______________________
6 Do you have any skin problems itching,
moles, etc
____________________ Yes No
7 Have you ever had a concussion? ___________________________________
Yes No
If yes, how many and when? ____________________________________
Have you ever had a seizure? _______________________________________
Yes No
Have you ever had a stinger or burner?
____________________________ Yes No
8 Have you ever injured sprained, dislocated, fractured, etc one of
the following
structures indicate R or L:
_____hand _____wrist _____forearm _____elbow _____arm
_____shoulder
_____neck _____chest _____back _____hip _____thigh _____knee
_____shin _____calf _____ankle _____foot
Please indicate type of injury, date of injury, and any limitations or
continuing problems:
____________________________________________________________________________
__
____________________________________________________________________________
__
9 Have you ever had heat cramps?
Yes No
Have you ever been dizzy or passed out in the heat?
Yes No
10 Have you ever had one of the following in the last 12 months note
ones you have or have had with a
check mark:
_____mononucleosis _____hepatitis _____asthma
_____tuberculosis
_____diabetes _____headaches freq _____eye injury
_____stomach ulcer
11 Have you been advised by a physician or by your parents not to
participate
in athletic events?
Yes No
12 Have you been treated for a disease or illness during the past 12
months? Yes No
______________________________________________________________
13 Are you currently under the care of a physician?
_______________________ Yes No
______________________________________________________________
14 Have you been found to have only one organ of usually paired organs
Yes No
ex: kidney, eye? _______________________________________________
15 Do you wear ____ Glasses ____ Contacts
Do you wear ____ Dental bridges ____ Plates ____ Braces
16 Do you use ____Special pads ____ Braces __________________________
17 When was your last tetanus shot date? ______________________
Confidential Health Questionnaire
Have you ever been treated for anemia?
Yes No
How many meals do you eat each day? _____ How many snacks? _____
Are there certain
food groups you refuse to eat ex: meats, breads
____________________________
Have you ever been on a diet?
Yes No
What is your present weight? __________ Are you happy with this weight?
Yes No
If not, what would you like to weigh? __________
Have you ever tried to control your weight by the following methods? check
all that apply:
_____vomiting _____diuretics _____diet pills _____using
laxatives
Have you ever expressed a concern that you might have an eating disorder
like
bulimia or anorexia? Yes
No
Has anyone ever expressed a concern that you might have an eating disorder?
Yes No
Have you been treated for an eating disorder?
Yes No
Do you have questions about healthy ways to control weight?
Yes No
For Men Only
Do you perform testicular exams on a regular basis?
________________________ Yes No
For Women Only
How old were you when you had your first menstrual period?
___________________
How often do you have a period? __________________________________________
How long do your periods last? ___________________________________________
How many periods have you had in the last 12
months?
________________________
Do you ever experience cramps during your period?
Yes No
If so, how do you treat them? _____________________________________________
Do you perform self breast exams on a regular basis?
_________________________ Yes No
With my signature, I, the undersigned, assure that the above is correct to
the best of my knowledge
______________________________________________
___________________________
Signature of Athlete Date
5/08
