Medical History Form - Michigan High School Athletic Association printable pdf download

MEDICAL HISTORY: Completed by Parent or Guardian or 18-Year-Old

Completed by Parent or Guardian or 18-Year-Old

Student Name: ____________________________________________________ Date of Exam: _____________________________

Family Doctor: ____________________________________________________ Phone: __________________________________

XXXX- GENERAL QUESTIONS

XXXX- MEDICAL QUESTIONS

Has a doctor ever denied or restricted your participation in sports for any reason?

Do you cough, wheeze or have difficulty breathing during or after exercise?

Do you have any ongoing medical conditions? If so, please identify below:

Have you ever used an inhaler or taken asthma medicine?

XXXq Asthma

q Anemia

q Diabetes

q Infections

q Other:

Is there anyone in your family who has asthma?

Have you ever spent the night in the hospital or have you ever had surgery?

Were you born without, or missing a kidney, eye, testicle (males), spleen or any other organ?

XXXX- HEART HEALTH QUESTIONS ABOUT YOU

Do you have groin pain or a painful bulge or hernia in the groin area?

Have you ever passed out or nearly passed out DURING or AFTER exercise?

Have you had infectious mononucleosis (mono) within the last month?

Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Do you have any rashes, pressure sores or other skin problems?

Does your heart ever race or skip beats (irregular beats) during exercise?

Have you had a herpes or MRSA skin infection?

Has a doctor ever told you that you have any heart problems? Check all that apply:

Do you have headaches or get frequent muscle cramps when exercising?

XXXq High blood pressure q Heart murmur q Heart infection q High cholesterol

Have you ever become ill while exercising in the heat?

XXXq Kawasaki disease q Other:

Do you or someone in your family have sickle cell trait or disease?

Has a doctor ordered a test for your heart? (example, ECG/EKG, echocardiogram)

Have you had any problems with your eyes or vision or any eye injuries?

Do you get lightheaded or feel more short of breath than expected during exercise?

Do you wear glasses or contact lenses?

Do you have a history of seizure disorder or had an unexplained seizure?

Do you wear protective eyewear such as goggles or a face shield?

Do you get more tired or short of breath more quickly than your friends during exercise?

Immunization History: Are you missing any recommended vaccines?

XXXX- HEART HEALTH QUESTIONS ABOUT YOUR FAMILY

Do you have any allergies?

Has anyone in your family had unexplained fainting, unexplained seizures or near drowning?

Have you ever had a head injury or concussion?

Does anyone in your family have a heart problem, pacemaker or implanted defibrillator?

Do you have any concerns that you would like to discuss with a doctor?

Has any family member or relative died of heart problems or had an unexpected or unexplained sudden

Have you ever received a blow to the head that caused confusion, prolonged headache or

death before age 50 (including drowning, unexplained car accident or sudden infant death syndrome)?

memory problems?

Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic

Have you ever had numbness, tingling, weakness or inability to move your arms or legs

right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome or

after being hit or falling?

catecholaminergic polymorphic ventricular tachycardia?

Have you ever had an eating disorder?

XXXX- BONE AND JOINT QUESTIONS

Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or a game?

Do you worry about your weight?

Have you ever had any broken or fractured bones, dislocated joints or stress fracture?

Are you trying to or has anyone recommended that you gain or lose weight?

Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches?

Are you on a special diet or do you avoid certain types of foods?

Do you regularly use a brace, orthotics or other assistive device?

XXXX- FEMALES ONLY (Optional)

Do you have a bone, muscle or joint injury that bothers you?

Have you ever had a menstrual period?

Do any of your joints become painful, swollen, feel warm or look red?

How old were you when you had your first menstrual period?

Do you have any history of juvenile arthritis or connective tissue disease?

How many periods have you had in the last 12 months?

Have you ever had an x-ray for neck instability or atlantoaxial instability (Down syndrome or dwarfism)?

CURRENT-YEAR PHYSICAL = GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

PHYSICAL EXAMINATION & MEDICAL CLEARANCE: Completed by MD, DO, PA or NP

RETURN DIRECTLY TO PATIENT

EXAMINATION: Height:

Weight:

Male

Female

BP:

Pulse:

Vision: R 20/

L 20/

Corrected:

MEDICAL

NORMAL

ABNORMAL

MUSCULOSKELETAL

NORMAL

ABNORMAL

Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

Neck

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/Ears/Nose/Throat:

Pupils Equal

Hearing

Back

Lymph nodes

Shoulder/Arm

Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)

Elbow/Forearm

Pulses: Simultaneous femoral and radial pulses

Wrist/Hand/Fingers

Lungs

Hip/Thigh

Abdomen

Knee

Genitourinary (males only)

Leg/Ankle

Skin:

HSV:

Lesions suggestive of MRSA, tinea corporis

Foot/Toes

Neurologic

Functional Duck Walk

RECOMMENDATIONS: _____________________________________________________________________________________________________________

I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities NOT crossed out below.

BASEBALL – BASKETBALL – BOWLING – COMPETITIVE CHEER – CROSS COUNTRY – FOOTBALL – GOLF – GYMNASTICS – ICE HOCKEY

LACROSSE – SKIING – SOCCER – SOFTBALL – SWIMMING/DIVING – TENNIS – TRACK & FIELD – VOLLEYBALL – WRESTLING

Name of Examiner (print/type): ______________________________________________________ Date: ____________________________

Signature of Examiner: ___________________________________________ (Check One): q MD

q DO

q PA

q NP

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - (DETACH HERE IF NEEDED TO ACCOMPANY STUDENT-ATHLETE) - - - - - - - - - - - - - - - - - - - - - - - - - - - -

EMERGENCY INFORMATION: COMPLETED BY PARENT or GUARDIAN or 18-YEAR-OLD

Student: ______________________________ Grade: ______ Doctor: _________________________________ Phone: (______)___________________

IN EMERGENCY (1): ______________________________________ Home #: (______)_________________________ Cell #: (______)____________________

IN EMERGENCY (2): ______________________________________ Home #: (______)_________________________ Cell #: (______)____________________

Drug Reactions: __________________________________________ Current Medications: _________________________________________________________

Allergies: ______________________________________________________________________________________________________________

FORM A: FEB-20-17

Medical History Form - Michigan High School Athletic Association

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