Section: Athletic Training Services Subject: Medical History Questionnaire
Purpose: To define the form to be used for the Medical History of an SBU student-athlete.
Policy: The following form must be filled out prior to any student-athlete participation in any practice or game at SBU.
MEDICAL HISTORY QUESTIONNAIRE
TODAY’S DATE_________________ Name:______________________________________________________
Social Security Number:___________________________________________
Sport:___________________________________
Parent or Guardian Name:__________________________________________________________________________________________________________ Parent or Guardian Home Address:_________________________________________________________
__________________________________________________________
Parent/Guardian Home Phone:____________________________________
Parent/Guardian Work Phone:_______________________________________
EMERGENCY CONTACT INFORMATION Name:_______________________________________________
Relationship:_______________________ Phone Number________________________
Address:________________________________________________________________________________________________________________________
PERMISSION TO TREAT: I give permission for SBU Team Physicians, SBU Athletic Training Services and CMH Sports Medicine to perform evaluations and treatment for injuries occurred in my sport. I understand that medical expenses incurred for medical care that is not from an injury incurred in my sport are my responsibility.
Signed:_______________________________________________
Parent/Guardian Signature:________________________________________
This is a confidential record of your medical history. Information contained here will not be released to anyone except when you have authorized us to do so. Please circle answers and provide information/details with any “YES” answers. Attach documents or medical records where necessary.
____________________________________________
____________________________________________
1.__________________________________________
2.__________________________________________
3.__________________________________________
4.__________________________________________
Weight: Now_________ One year ago_______
Fractured, broken, cracked bones Yes / No
CONTINUED ON BACK
List all sprains, strains, dislocations and fractures you’ve had in the last 5 years: ______________________________________________________________ List all surgeries/operations you’ve had in the last 5 years:________________________________________________________________________________ Have you ever been advised to have surgery which has not been done? Yes / No If yes, please give details:_______________________________________ Have you ever been advised by a physician to not participate in sports? Yes / No If yes, please give details:_________________________________________ Have you ever been hospitalized? Yes / No If yes, please give details:______________________________________________________________________ PLEASE REQUEST AND SEND/BRING PHYSICIAN’S REPORTS TO YOUR ATHLETIC TRAINER ON ANY SURGERY OR HOSPITALIZATIONS YOU’VE HAD IN THE LAST 5 YEARS DO YOU HAVE NOW, OR HAVE YOU HAD ANY OF THE FOLLOWING IN THE LAST YEAR? Frequent or severe headache Recurrent back pain IMMUNIZATIONS / Date Fainting spells Recurrent neck pain Tetanus_________________ Migraines Joint pains Diptheria________________ Blurred vision Swelling of any joints Polio____________________ Double vision Osgood Schlatter’s Measles (Rubella)_________ Spots before eyes Patellar chondromalacia Mumps or MMR___________ Infected eyes Tingling/weakness of hands/feet Smallpox________________ Pain behind eyes Muscle spasms/cramps Chicken pox______________ Do you wear glasses Tiredness without apparent reason Tuberculosis_____________ If yes, when were they last checked?________ Easy bruising Hepatitis_________________ Do you wear contacts Inability to stand heat Inability to stand cold Any skin rash During competition Heat exhaustion Earaches Heat stroke Discharge from ears Pain in arm(s) Ringing in ears Night sweats Decrease in hearing Chronic or frequent coughs Hearing problems Chronic or frequent cough when Recurrent nosebleeds laying down Recurrent head colds Wake up at night short of breath Sinus trouble Purple lips or fingers Hay fever Palpations or fluttering heart beat Strange, persistent odors High or low blood pressure Strange taste or loss of taste Swelling of hands, feet or ankles Persistent hoarseness Dizziness with activity Difficulty swallowing Leg cramps on waking or at night Enlarged glands Recurrent stomach pain/heartburn Recurrent sore throats Nausea or vomiting Recurrent sores in mouth Abdominal cramps Soreness or bleeding of gums Dark black bowel movement Chest pain Pain on urinating Coughed up blood Any blood with urinating Wear orthotics CHECK ANY MEDICATIONS/SUPPLEMENTS YOU ARE TAKING: Accutane_________ I certify that all answers to the above statements are correct and true. I understand that Southwest Babtist University is not responsible for any previous medical conditions I might have. Signed:________________________________________ Date:_______________ Witness:___________________________________________ Student/Athlete Certified Athletic Trainer
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