Participant Medical History Questionnaire Form

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NAME: LAST_________________________________ FIRST_________________________SPORT: _______________________________________

DATE OF BIRTH: MONTH______________ DAY ______________ YEAR _____________SEX: MALE_____ FEMALE____

ADDRESS: _______________________________________ CITY: __________________________________ STATE: ___________ZIP: __________

EMERGENCY CONTACT:

PARTICIPANT’S PHONE: ________________________________

NAME: ___________________________________________ PHONE: Cell________________________Home_______________________

Yes

No

Has the participant ever had?

Yes

No

Has the participant ever had?

1.

______

______

Chronic or recurrent illness or injury?

18.

______

______

Asthma?

2.

______

______

Any illness lasting more than (1) week?

19.

______

______

Epilepsy or other seizures?

3.

______

______

Mononucleosis or Rheumatic fever?

20.

______

______

Diabetes?

4.

______

______

Hospitalizations (Overnight or longer)?

21.

______

______

Herpes infection?

5.

______

______

Surgery, other than tonsillectomy?

22.

______

______

Marfan Syndrome?

6.

______

______

Missing organ (eye, kidney, testicle)?

23.

______

______

Eyeglasses or contact lenses?

7.

______

______

Allergies to pollen, stinging insect, food, etc.?

8.

______

______

High blood pressure or high cholesterol?

Yes

No

Is there a history of?

9.

______

______

24.

______

______

Injuries requiring medical treatment?

Heart problems (Racing, murmur, skipped

beats, infections, etc.?)

25.

______

______

Neck injury?

10.

______

______

Chest pressure or pain with exercise?

26.

______

______

Knee injury or surgery?

11.

______

______

Dizziness or fainting with exercise?

27.

______

______

Other serious joint injuries?

12.

______

______

Excessive shortness of breath with exercise?

28.

______

______

Use of protective equipment or braces?

13.

______

______

Seizures or frequent headaches?

29.

______

______

Do you know your sickle cell status?

14.

______

______

Head injury, concussion, unconsciousness?

30.

______

______

Has a doctor ever denied or restricted your

15.

______

______

participation in sports for any reason?

Numbness, tingling or weakness in arms or

legs with contact?

31.

______

______

Do you have any concerns that you would

16.

______

______

like to discuss with the doctor?

Headache, memory loss, or confusion with

contact?

17.

______

______

Severe muscle cramps or become ill when

exercising in the heat?

Yes

No

Family History:

32.

______

______

Does anyone in your family have Marfan syndrome?

33.

______

______

Has anyone in your family died suddenly for no apparent reason?

34.

______

______

Has anyone in your family had a heart attack at less than 55 years of age?

Use this space to explain any “YES” answers from above (questions #1-34) or to provide any additional information:

______________________________________________________________________________________________________________________

35. Are you allergic to any prescription or over-the-counter medications? Do you have any food allergies? If yes, list: _____________________

___________________________________________________________________________________________________________________

-Do you have a therapeutic use exemption? ________________________________________________________________________

36. List all medications you are presently taking (including asthma inhalers & EpiPens) and the condition the medication is for:

A.__________________________________ B._________________________________________

C.____________________________________

37. Year of last known: Tetanus (lockjaw) vaccination: ___________________________Meningitis vaccination: ________________________

38. What is the most and least you have weighed in the past year? Most_________________________ Least_________________________

39. Are you happy with your current weight? Yes______ No_______

FOR FEMALES ONLY:

1. How old were you when you had your first menstrual period? ____________________________________________

2. In the past 12 months, what is the longest time you have gone between menstrual periods? ____________________

I hereby state that the questions on this form have been answered completely and truthfully to the best of my knowledge.

___________________________________

_______________________________________________

Signature of Participant

Date

FOR ATHLETES OF MINORITY OF AGE

This is to certify that I, as the parent/guardian of this participant, have explained to my son/daughter the aforementioned stipulated conditions and their ramifications, and I

consent to his/her participation in the programs conducted at this USOTC, and consent to the provisions of medical, psychological or psychiatric care and treatment,

emergency medical services, transportation, housing and meals associated with participation in programs conducted at this United States Olympic Training Center. In the

event that emergency medical services are required, I hereby authorize the USOC to act to resolve such emergency without first obtaining my prior consent or the

consent of the participant’s next of kin or any other individual.

_______________________________________________________________________

_________________________________________________________

Parent/Guardian Signature

Date

_______________________________________________________________________

_________________________________________________________

Parent/Guardian Name (Please Print)

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