Fillable Medical History Questionnaire

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Medical History Questionnaire

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The Medical History Questionnaire form is 2 pages long and contains:

  • 2 signatures
  • 21 check-boxes
  • 106 other fields

Country of origin: US
File type: PDF

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DSC CREATIVE 5511/6-2009
Pre-Participation
Physical Examination
Name: _____________________________________________________________________ Sport: ______________________________
SS#: __________ - _______ - ___________ Date of birth: ______ / ______ / __________ Sex: c M c F
Permanent (home) address:
_______________________________________________________________________________________
.............Street .............. City State ............ Zip .............. Phone
My permanent address is with: c mother c father c both biological parents
Local address: ___________________________________________________________________________________________________
...............Street .............. City State ............ Zip .............. Phone
Cell Phone: ___________________________________
Explain yEs answErs in spacE providEd
................................................................................................. Yes No
1. Have you ever been hospitalized? (explain) c c
Have you ever had surgery? (explain) c c
2. Are you presently taking any medications or pills? If yes, what are they? c c
3. Do you have any allergies (medicine, bees or other stinging insects)? c c
4. Have you ever passed out during or after exercise? c c
Have you ever been dizzy during or after exercise? c c
Have you ever had chest pain during or after exercise? c c
Have you ever had high blood pressure? c c
Have you ever had racing of your heart or skipped heartbeats? c c
Has anyone in your family died of heart problems or a sudden death before age 50? c c
5. Do you have any skin problems (itching, rashes, acne)? c c
6. Have you ever had a head injury? If yes, when? (year) c c
Have you ever been knocked unconscious? If yes, when? (year) c c
Have you ever had a seizure? If yes, when? (year) c c
Have you ever had a stinger, burner, or pinched nerve? If yes, when? (year) c c
7. Have you ever had heat or muscle cramps? c c
Have you ever been dizzy or passed out in the heat? c c
8. Do you have trouble breathing or do you cough during or after activity? c c
9. Do you use any special equipment (pads, braces, mouth guard, eye guards, etc.)? c c
10. Have you had any problems with your eyes or vision? c c
Do you wear glasses or contacts or protective eye wear? c c
-1-
■
Pre-Participation Physical Examination (continued) Yes No
11. Have you ever sprained/strained, dislocated, fractured, broken or had repeated swelling
or other injuries of any bones or joints? c c
Please check: c head ... ........c shoulder ..... c thigh ............ c neck ............. c elbow .....
c chest c hand ............c forearm ...... c back ............. c shin/calf ....... c ankle ...........
c wrist c hip ...............c knee ........... c foot
12. Have you had any other medical problems? c c
c asthma c anemia c hypoglycemia c diabetes c infectious mononucleosis c other
13. When was your last tetanus shot? (year) _______________
14. Do you smoke? c c
Use other tobacco products? c c
15. What is your present weight? __________ lbs.
16. Are you happy with this weight? c c
If not, what would you like to weigh? __________ lbs.
17. Have you ever tried to control your weight by:
a) vomiting? c c
b) using laxatives? c c
c) taking diuretics (water pills)? c c
d) diet pills? c c
18. Have you ever been diagnosed as having an eating disorder? c c
19. Do you have questions about healthy ways to control weight? c c
20. Are there any additional health problems that you would prefer
to discuss privately with our team physician? c c
Women Only
21. When was your first menstrual period? _______________
22. When was your last menstrual period? _______________
23. What was the longest time between your periods last year? _______________
24. Is there a possibility that you could be pregnant? c c
25. How many urinary tract infections (bladder/kidney) have you had in the last year? _______________
26. Have you ever had a pelvic (female) exam? c c
When was your last pelvic exam?_______________
Have you ever had an abnormal PAP smear? c c
Please read carefully and sign below
I understand that failure to disclose accurate information could result in my being ineligible to participate in practices or events on a Daytona State College inter-
collegiate athletic team. I understand I must not practice or play during medical treatment for any injury or illness until I am discharged from treatment or given a
written permit by the attending physician to resume participation. I understand that having passed the physical examination does not necessarily mean that I am
physically qualified to participate in athletics, but only that the examiner did not find a medical reason to disqualify me. I understand that Daytona State College
is not financially responsible for injury or illness that occurs outside a Daytona State College scheduled and sanctioned practice or event. I understand that failure
to follow the procedures outlined in the Athletic Injury, Illness and Medical Care Procedures Brochure will result in my being ineligible to participate in practices
or events on a Daytona State College intercollegiate athletic team.
___________________________________________________________ _____________________________________________________________
Athlete’s printed name ............................................................... Athlete’s signature
Parent's signature (if minor): __________________________________________________________________________________________________
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Medical History Questionnaire

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Completed 1 November 2019

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