Sample Medical History Questionnaire Page 2
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10. Have you ever been told by a doctor that you have asthma?
NO
YES
(list any medication)
________________________________________________
11. Do you have or have you ever had a hernia or “rupture”?
NO
YES
(if so, has it been repaired?)
_______________________________________
12. Have you been “knocked out” or become unconscious in the past three years?
NO
YES
(if so, describe and give date(s)
____________________________________
13. Have you had a concussion or other head injury in the past three years?
NO
YES
(if so, describe and give date(s)
____________________________________
14. Have you stayed overnight in a hospital due to a head injury?
NO
YES
(if so, list date(s)
_________________________________________________
15. Have you ever had a neck injury involving bones, nerves, or disks that disabled you for a
week or longer?
NO
YES
Type of injury ________________________ Date(s) ______________
16. Do you wear glasses or contacts during competition?
No
YES
17. Do you wear any of the following dental appliances:
NO
YES
(Circle those that apply)
Permanent bridge
Braces Removable retainer
Permanent retainer
Removable partial plate
Full plate
Permanent crown or jacket
18. Have you had a broken bone (fracture) in the past two years?
NO
YES
What bone? ______________________ right or left? ____________ Dates ________
19. Have you had a shoulder injury in the past two years that disabled you for a week or
longer (dislocation, separation, etc.)?
NO
YES
Type of injury ______________________ right or left? _________ Dates ___________
20. Have you ever had shoulder surgery?
NO
YES
What was done and why?
_____________________________________________
right or left? _____________ Dates _______________
21. Have you ever injured your back?
NO
YES
Type of injury __________________________________ Date (s)
22. Do you have back pain?
NO
YES
(Circle any that apply)
Seldom
Occasionally Frequently
With Vigorous Exercise
With Heavy
Lifting
23. Have you injured your knee in the past two years?
NO
YES
24. Have you been told by a doctor or athletic trainer that you injured the cartilage in your
knee?
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