Participation Physical History

Preparticipation Physical History 2010
Email and email verification
(MM/DD/YYYY)
(MM/DD/YYYY)

Medicines and Allergies

Do you have allergies?
Are you allergic to any of the following?

GENERAL QUESTIONS. Explain "Yes" answers.

1. Has a provider ever denied or restricted your participation in sports for any reason?
2. Do you have any ongoing medical? If so, please identify below:
3. Have you ever spent the night in the hospital?
4. Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU

5. Have you ever passed out or nearly passed out During or After exercise?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
7. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply.
9. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
10. Do you get light-headed or feel shorter of breath than your friends during exercise?
11. Have you ever had an unexplained seizure?
12. Do you get more tired or short of breath more quickly than your friends during exercise?

HEART HEALTH QUESITONS ABOUT YOUR FAMILY

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 years (including drowning, unexplained car crash, or sudden infant death syndrome)?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia?
15. Has anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?

BONE AND JOINT QUESTIONS

17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?

MEDICAL QUESTIONS

26. Do you cough, wheeze, or have diffculty breathing during or after exercise?
27. Have you ever used an inhaler or taken asthma medicine?
28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
31. Have you had infectious mononucleosis (mono) within the last month?
32. Do you have any rashes, pressure sores, or other skin problems?
33. Have you had a herpes or MRSA skin infection?
34. Have you ever had a head injury or concussion?
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
36. Do you have a history of seizure disorder?
37. Do you have headaches with exercise?
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
39. Have you ever been unable to move your arms or legs after being hit or falling?
40. Have you ever become ill while exercising in the heat?
41. Do you get frequent muscle cramps when exercising?
42. Do you or someone in your family have sickle cell trait or disease?
43. Have you had any problems with your eyes or vision?
44. Have you had any eye injuries?
45. Do you wear glasses or contact lenses?
46. Do you wear protective eyewear, such as goggles or a face shield?
47. Do you worry about your weight?
48. Are you trying to or has anyone recommended that you gain or lose weight?
49. Are you on a special diet or do you avoid certain types of foods?
50. Have you ever had an eating disorder?
51. Do you have any concerns that you would like to discuss with a doctor?

FOR FEMALES ONLY

52. Have you ever had a menstrual period?

Explain all Yes answers

(MM/DD/YYYY)