DATE OF EXAM________________________________
Medicines: Please list all prescription & over the counter medicines & supplements (herbal & nutritional) that you are taking.
__________________________________________________________________________________________________________________________________________
Do you have any allergies: □ Yes □ No If yes, please specify allergy below:
□Medicines □ Pollens □ Food □ Insect Stings
Other:_____________________________________________________________________________________________________________________________________
Name ________________________________________________ Sex_____
Date of Birth_______________
Grade _________
School______________________________
Sport(s) _____________________________________
Address _______________________________________________________
Home Phone ________________________________
Personal Physician _____________________________________________ Physician Phone _____________________________
In Case of emergency, Contact
Mother/Guardian_________________________________________ Father/Guardian___________________________________________
Preferred Phone_________________________________ Preferred Phone _________________________________
Explain "Yes" answers below. Circle questions you don't know the answers to.
GENERAL QUESTIONS Yes No Medical Questions Yes No
1. Has a doctor ever denied or restricted your 26. Do you cough, wheeze or have difficulty
participation in any sports for any reason? breathing during or after exercise?
2. Do you have an ongoing medical condition? If so, please Identify
27. Have you ever used an inhaler or taken asthma medicine?
□ □
Below: □ Asthma □ Anemia □ Diabetes □ Infections
28. Is there anyone in your family who has asthma?
□ □
Other:_________________________________________ 29. Were you born without or are you missing a
3. Have you ever spent the night in the hospital?
□ □
kidney, eye, testicle or any other organ?
4. Have you ever had surgery?
30. Do you have groin pain or painful bulge in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU
YES NO 31. Have you had infectious mononucleosis (mono) in the last month?
5. Have you ever passed out or nearly passed out
32. Do you have any rashes, pressure sores, or other Skin problems?
33. Have you had a herpes or MRSA Skin infection?
6. Have you ever passed out or nearly passed out
34. Have you ever had a head injury or concussion?
AFTER exercise? 35. Have you been hit in the head and been confused,
7 Have you ever had discomfort, pain or pressure prolonged headache or memory problems?
in your chest during exercise? 36. Do you have a history of seizure disorder? □ □
8. Does your heart race or skip beats during exercise? □ □ 37. Do you have headaches with exercise? □ □
9. Has your doctor ever told you that you have: 38. Have you ever had numbness, tingling, or weakness in your
(Check all that apply) □ A Heart Murmur
arms or legs after being hit?
□ High Blood Pressure □ A Heart Infection
39. Have you ever been unable to move your arms or legs after
□ High Cholesterol □ OTHER
being hit or falling?
10. Has a doctor ever ordered a test for your heart?
40. Have you ever become ill while exercising in the heat?
□ □
(for example ECG or echocardiogram) 41. Do you get frequent muscle cramps when exercising?
□ □
11. Has anyone in your family died for no apparent reason?
□ □
42. Do you or someone in your family have sickle cell trait or disease?
12. Does any one in your family have a heart problem?
□ □ 43. Have you had any problems with your eyes?
□ □
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY YES NO 44. Have you had any eye injuries?
□ □
13. Has any family member or relative died of heart 45. Do you wear glasses or contact lenses?
□ □
problems or of sudden death before age 50? Including
46. Do you wear protective eyewear such as a face shield or goggles?
□ □
drowning, unexplained car accident or sudden infant death? 47. Do you worry about your weight?
□ □
14. Does anyone in your family have hypertrophic cardiomyopathy,
48. Are you trying to or has anyone recommend that you gain or
marfans syndrome, arrhythmogenic right ventricular cardio- lose weight?
myopathy, Long QT syndrome, short QT syndroms, Brugada Syndrome,
49. Are you on a special diet or do you avoid certain foods? □ □
or catecholaminergic polymorphic ventricular tachycardia?
50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker or
Do you have any concerns you would like to discuss with a doctor?
implanted defibrillator? FEMALES ONLY
16. Has anyone in your family had unexplained fainting, 52. Have you ever had a menstrual period? □ □
seizures or drowning? 53. How old were you when you had your first period?
BONE AND JOINT QUESTIONS
YES NO
54. How many periods did you have last year?
17. Have you ever had an injury like a sprain, muscle or ligament
Explain "Yes" answers here
:______________________________________
tear or tendinitis, that caused you to miss practice or game?
______________________________________________________________
18. Have you had any broken or fractured bones or dislocated joints?
□ □
______________________________________________________________
19. Have you had a bone or joint injury that required x-rays, MRI, CT,
______________________________________________________________
surgery, injections, rehabilitation, physical therapy, a brace,
______________________________________________________________
______________________________________________________________
20. Have you ever had a stress fracture?
□ □
______________________________________________________________
21. Have you been told that you have had or have you had an x-ray
______________________________________________________________
for atlantoaxial (neck) instability?
______________________________________________________________
22. Do you regularly use a brace or assistive device?
□ □ ______________________________________________________________
23. Do you have a 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?
□ □ ______________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of student___________________________ Signature of parent/guardian__________________________________Date ___________
©2010 American Academy of Famiy Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic
Society for Sports Medicine, and American Osteopathic Academy of Sports medicine. Permission is granted to reprint for non commercial, educational purposes with acknowledgement.
□□
Please upload directly to
student-athlete's
Magnus Health Account,
located in the parent
portal. Hard copies or
emailed copies
will NOT be accepted.
Physical Exam Questionnaire
