Medical History Form
Student’s Name:
SS#:
Date of Birth:
Sex: Male
Family Doctor
or Clinic:
-
Female
Family Dentist
or Clinic:
YES
1. Has anyone in your family under age 50 died
suddenly from causes other than accident?
-
NO
YES
NO
10. During the past 12 months:
a. was he/she hospitalized?
b. have illnesses lasting more than 1 week
Explain:
11. Do you know of any reason why there should be limits
placed on his/her participation in any sport?
2. Have you had or do you now have:
Brain concussion (head injury)?
Tendency to lose consciousness (faint)?
Skull fracture?
Convulsions or epilepsy?
Neck injury?
3. Have you had or do you now have:
Brain concussion (head injury)?
Tendency to lose consciousness (faint)?
Temporary loss of vision?
4. Do you NOW (or within the past 12 months)
have: Hernia?
Kidney problems?
5. Do you NOW (or within the past 12 months)
have: Bone fracture (date)?
12. Is he/she missing any paired organ (eyes, kidney,
testicle, etc.)?
13. Do you want to talk to a doctor about a health
problem or an injury?
14. During the past 12 months did he/she have injuries
requiring medical attention?
Explain:
15. Has anyone in your close family ever had:
Diabetes (high sugar in blood or urine)?
Heart trouble?
High blood pressure?
16. Have you had or do you now have:
Hearing loss?
Perforated ear drum?
6. Have you had or do you now have:
Diabetes (high sugar in blood or urine)?
Tendency to bleed or bruise easily?
7. Have you had or do you now have:
Heart trouble or mummer?
High blood pressure?
Persistent cough?
Chest pain with exercise:
Dizziness or faintness with exercise?
8. Do you wish to discuss an emotional problem
with a doctor?
9. Have you ever been told to give up sports for
health problems?
Date of Last Tetanus Booster
17. Have you had or do you now have:
Asthma (wheezing)? (If yes, do you
actively wheeze when exercising)?
Do you take medications for wheezing?
Bee sting reactions (allergy)?
If yes, do you require injectable medications?
Reaction to medications (allergy)?
List:
18. Do you:
Smoke?
Take any medications regularly? (If yes,
please list:
Take any medications for emergency use?
If yes, please list:
I hereby certify that he above form has been reviewed and answered correctly. I also understand that the athletic screening
physical to be performed on me is only a screening physical. It does not replace a complete physical that could be performed by
family physician.
Signature of Patient: ____________________________________________
Date: _____________________________