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Athlete Medical History

Fill out your name, blugold id number, and the sport(s) you will be participating in. You can then answer all applicable questions below. After you've completed the form, print out the page and bring the print out to your appointment.

Name ID # Date

Please read each question carefully, and check YES or NO by each question.

Yes No Question
1. Have you ever been advised not to participate in any sports?
2. Is there any reason you possibly should not participate now?
3. Have you ever been told you have heart trouble?
4. Have you ever passed out during or after exercise?
5. Have you ever passed out for no apparent reason?
6. Have you ever experienced severe dizziness during or after exercise?
7. Have you ever had chest pain during or after exercise?
8. Does your heart ever beat unevenly or irregularly?
9. Has a family member or relative died of a heart problem or sudden (non-accidental) death before age 50?
10. Has a family member had a heart attack before age 50?
11. Have you ever had high blood pressure or high cholesterol?
12. Have you ever had anemia? (been anemic?)
13. Have you had mononucleosis in the past 3 months?
14. Are you using any performance-enhancing or weight control supplements?
15. Have you ever had severe head injury, been knocked out, or had concussion?
16. Have you ever had a seizure?
17. Have you or others been concerned about your weight or eating habits?
18. Have you or others been concerned about your alcohol or drug use?
19. Do you have a missing or non-functioning kidney?
20. Do you have asthma? If yes, is it well controlled with medication? (Y) (N)
21. Have you ever been ill from exercising in the heat?
22. Do you have a neck or back problem?
23. Do you have a shoulder, arm, wrist or hand problem?
24. Do you have a hip problem?
25. Do you have a leg, ankle, or foot problem?
26. Do you have a knee problem?
27. Do you have an unhealed injury now?
28. (MALES ONLY) Do you have a missing or non-functioning testicle?
29. (FEMALES ONLY) Are you having no periods at all, or periods which are usually more than 3 months apart?
30. (FEMALES ONLY) Is there a possibility that you are pregnant?
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