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ALVIN COMMUNITY COLLEGE
Student-Athlete Health History Questionnaire Form
The information contained in this medical history form will only be used by the Athletic Department of Alvin Community College
This information will remain CONFIDENTIAL at all times.
Part 1. Student Information (to be completed by student or parent)
Student’s Name:______________________________________________________ Sex:______ Age:______ Date of Birth:_____/_____/_____
Social Security #:_______________________ Sport(s):____________________ Email: ____________________________________________
Home Address: _________________________________________________________________________ Phone: _______________________
Personal Physician: __________________________________________________________ Office Phone: _____________________________
In case of emergency, contact: Name: _____________________________________________________________________________________
Relationship to Student-Athlete: ______________________________ Home Phone:__________________ Cell Phone:___________________
Part 2. Medical History(to be completed by student or parent). Explain “yes” answers below. Circle questions you don’t know answers to.
Yes No Yes No
1. Have you had a medical illness or injury since your ____ ____ 25. Have you ever had a stinger, burner, or pinched nerve? ____ ____
last check up or sports physical? 26. Have you ever become ill from exercising in the heat? ____ ____
2. Do you have an ongoing chronic illness? ____ ____ 27. Do you cough, wheeze or have trouble breathing ____ ____
3. Have you been hospitalized overnight? ____ ____ during or after activity?
4. Have you ever had surgery? ____ ____ 28. Do you have asthma? ____ ____
5. Are you currently taking any prescription or non- ____ ____ 29. Do you have seasonal allergies that require treatment? ____ ____
prescription (OTC) medications or pills or using an 30. Do you use any special protective or corrective
inhaler? equipment for your sport (knee brace, orthotics, etc.) ____ ____
6. Have you ever taken any supplements of vitamins to ____ ____ 31. Have you had any problems with your eyes or vision? ____ ____
help you gain or lose weight or improve your 32. Do you wear glasses, contacts or protective eyewear? ____ ____
performance? 33. Have you ever had a sprain, strain or swelling after ____ ____
7. Do you have any allergies (pollen, food, insect bites, etc) ____ ____ injury?
8. Have you ever had a rash or hives develop during or ____ ____ 34. Have you broken any bones or dislocated any joints? ____ ____
after exercise? 35. Have you had any other problems with pain or ____ ____
9. Have you ever passed out during or after exercise? ____ ____ swelling in muscles, tendons, bones or joints?
10. Have you ever been dizzy during or after exercise? ____ ____ If yes, check appropriate blank and explain below:
11. Have you ever had chest pain during or after exercise? ____ ____ ___ Head ___ Elbow ___ Hip ___ Shoulder
12. Do you get tired more quickly than your friends do ____ ____ ___ Neck ___ Forearm ___ Thigh ___ Finger
during exercise? ___ Back ___ Wrist ___ Knee ___ Ankle/Foot
13. Have you ever had racing of your heart or skipped ____ ____ ___ Chest ___ Hand ___ Shin/Calf___ Upper Arm
heartbeats? 36. Do you want to weigh more or less than you do now? ____ ____
14. Have you had high blood pressure or high cholesterol? ____ ____ 37. Do you feel stressed out? ____ ____
15. Have you ever been told you have a heart murmur? ____ ____ 38. When was your last tetanus shot? ____/____/___
16. Has any family member or relative died of heart ____ ____ 39. Have you ever been diagnosed with or treated for ____ ____
problems or sudden death before age 50? sickle cell trait or sickle cell disease?
17. Have you had a severe viral infection (for example, ____ ____
myocarditis or mononucleosis) within the last month?
18. Has a physician ever denied or restricted your ____ ____
participation in sports for any heart problems? Females Only
19. Do you have any current skin problems (for example, ____ ____ 40. When was your first menstrual period? _________________________
itching, rashes, acne, warts, fungus or blisters)? 41. When was your most recent menstrual period? ___________________
20. Have you ever had a head injury or concussion? ____ ____ 42. How much time do you usually have from the start of one period to
21. Have you ever been knocked out, become unconscious ____ ____ the start of another? ________________________________________
or lost your memory? 43. How many periods have you had in the last year? _________________
22. Have you ever had a seizure? ____ ____ 44. What was the longest time between periods in the last year? _________
23. Do you have frequent or severe headaches? ____ ____
24. Have you ever had numbness or tingling in your ____ ____
arms, hands, legs or feet?
Explain “yes” answers here: _______________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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*I hereby state that, to the best of my knowledge, my answers to the above questions are complete and accurate.
Signature of Athlete _______________________________________________________ Date _______________________
Signature of Parent/Guardian _______________________________________________ Date _______________________
