Sports Medicine - Interval Year Health Questionnaire Form
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1SPORTS MEDICINE
NCAA INTERVAL YEAR HEALTH QUESTIONNAIRE
STUDENT-ATHLETE’S NAME_________________________________________ SPORT___________________________
This annual form must be completed and returned before the student-athlete will be permitted to practice or play. The National
Collegiate Athletic Association’s policies recommend all student-athletes have a qualifying medical evaluation upon initial entrance
into an institutions intercollegiate athletic program, and an annual “health-status” review. Eastern Kentucky University supports this
NCAA policy. Further medical evaluations may be required for specific matters.
Date of your initial physical examination: ______________________ (i.e. Aug., 2013, (usually your first year at EKU, etc.)
st
1.
Have you been hospitalized or had a major illness since May 1
.
___Yes ___No
2.
Are you currently ill or injured in any way? __________________________________________________ ___Yes ___No
st
3.
Have you had a major injury (including cerebral concussion since your May 1
? ____________________ ___Yes ___No
4.
Do you currently have any incompletely healed injuries? _______________________________________ ___Yes ___No
st
5.
Have you had any operations or surgeries since May 1
? _______________________________________ ___Yes ___No
st
6.
Have you had any accidents and/or fractures since May 1
? ____________________________________
___Yes ___No
st
7.
Have you seen a physician for any reason May 1
? ____________________________________________ ___Yes ___No
Do you know of any health reason you should not participate in EKU’s intercollegiate athletic programs at this
8.
time?________________________________________________________________________________ ___Yes ___No
9.
Since last year have you experienced any chest pain or discomfort, rapid heartbeats, dizziness, nausea, dizzy,
asthma attack, heat related problems or seizures with exercise? _______________________________________Yes ___No
10. Has any family member died suddenly at less than 55 years of age from causes other than an accident?
___Yes ___No
11. Would you like to discuss your current health with a staff athletic trainer or team physician?
___Yes ___No
Are you currently taking any medications or drugs that we need to be aware of (prescribed medicine, self-medications, vitamins,
supplements, etc?)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
HT. ______________
WT._________________
BP _________________
PULSE__________
The undersigned herewith:
A. Understand he/she must refrain from practice while ill or injured, whether or not receiving medical treatment until discharged
from treatment or given permission by the clinical practitioner (ATC, MD, PA, etc.), to resume participation despite
continuing treatment/therapy.
B. Understands having passed the physical examination does not necessarily mean that he/she is physically qualified to engage
in intercollegiate athletics, but only that the evaluator did not find a medical reason warranting disqualification at the time of
the examination.
C. Certifies that the answers to these questions are correct and true.
SIGNATURE: __________________________________________
DATE: ________________________
ATC: __________________________________________________
DATE: ________________________
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