Medical History Questionnaire Form
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1OLYMPIC DEVELOPMENT PROGRAM
MEDICAL HISTORY QUESTIONNAIRE
LAST NAME
FIRST NAME
MIDDLE INITIAL_______
ADDRESS
_________
CITY
STATE
ZIP
DATE OF BIRTH_______-_______-_______
SEX _____M _____F
SOCIAL SECURITY NUMBER__________-_________-
EMERGENCY CONTACT
HM PH (_____)_____________________WK PH (_____)
________
PLEASE CIRCLE EITHER “YES” OR “NO” TO ALL QUESTIONS AND PROVIDE ADDITIONAL DETAILS WHERE REQUESTED. YOU MAY PUT DETAILS ON
THE BACK OF THIS FORM IF NEEDED. ALL INFORMATION IS CONFIDENTIAL.
1) ARE YOU ALLERGIC TO ANY MEDICATION (ASPIRIN, PENICILLIN, SULFA, ETC)? YES NO (LIST)
__________
2) DO YOU TAKE ANY PRESCRIBED MEDICATION ON A PERMANENT BASIS OR SEMI-PERMANENT BASIS (STEROIDS, BIRTH CONTOL PILLS, ANIT-
INFLAMMATORIES, ANTIBIOTICS, ETC)? YES NO (LIST & GIVE REASON)
_____
____
3) HAVE YOU EVER HAD ANY EPILEPTIC SIEZURE? YES NO
4) HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU HAVE EPILEPSY? YES NO (LIST MEDICATION)
5) HAVE YOU EVER BEEN TREATED FOR DIABETES? YES NO
6) HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU WERE ANEMIC? YES NO WHEN?
_
7) HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU HAVE SICKLE CELL ANEMIA? YES NO
8) HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU HAVE SICKLE CELL TRAIT? YES NO
____
9) DO YOU HAVE OR HAVE YOU EVER HAD HIGH BLOOD PRESSURE? YES NO (LIST MEDICATION)
_________________
10) DO YOU HAVE OR HAVE YOU EVER HAD THE FOLLOWING DISEASES?
HEART DISEASE (HEART MURMER, RHEUMATIC FEVER) YES NO (GIVE DATE)
_______
LUNG DISEASE (PNEUMONIA) YES NO (GIVE DATE)
KIDNEY DISEASE (INFECTIOUS) YES NO (GIVE DATE)
___
LIVER DISEASE (MONONUCLEOSIS, HEPATITIS) YES NO (GIVE DATE)
_______
11) DO YOU HAVE OR HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU HAVE ASTHMA? YES NO (LIST MEDICATION)
_________
12) DO YOU HAVE OR HAVE YOU EVER HAD A HERNIA OR “RUPTURE”? YES NO HAS IT BEEN REPAIRED?
_
DATE
13) HAVE YOU EVER BEEN “KNOCKED OUT”(UNCONSCIOUS) IN THE PAST 3 YEARS? YES NO (LIST DATES)
14) HAVE YOU EVER HAD A CONCUSSION OR OTHER HEAD INJURY IN THE PAST 3 YEARS? YES NO (LIST DATES) _________________
15) HAVE YOU STAYED OVERNIGHT IN THE HOSPITAL DUE TO A HEAD INJURY? YES NO (LIST DATES)
_________________
16) HAVE YOU EVER HAD A NECK INJURY INVOLVING BONES, NERVES, OR DISKS THAT DISABLED YOU FOR A WEEK OR LONGER?
YES NO TYPE OF INJURY
DATES
17) DO YOU WEAR GLASSES OR CONTACTS DURING COMPETITION? YES NO
18) DO YOU WEAR ANY OF THE FOLLOWING DENTAL APPLIANCES? YES NO (CIRCLE THOSE WHICH APPLY) PERMANENT BRIDGE, BRACES,
REMOVABLE RETAINER, PERMANENT RETAINER, REMOVABLE PARTIAL PLATE, FULL PLATE, PERMANENT CROWN OR JACKET?
19) HAVE YOU HAD A BROKEN BONE OR FRACTURE IN THE PAST 2 YEARS? YES NO _____RIGHT OR_____LEFT
WHAT BONE(S)
__________________________________
____DATES
20) HAVE YOU EVER HAD A SHOULDER INJURY IN THE PAST 2 YEARS THAT DISABLED YOU FOR A WEEK OR LONGER? (DISLOCATION, SEPARATION,
ETC) YES NO
_____RIGHT OR_____LEFT
TYPE OF INJURY
DATE
21) HAVE YOU EVER HAD SHOULDER SURGERY? YES NO _____RIGHT OR _____LEFT
DATE
_________
WHAT WAS DONE AND WHY?
22) HAVE YOU EVER INJURED YOUR BACK? YES NO TYPE OF INJURY
__________
DATE
23) DO YOU HAVE BACK PAIN? YES NO (CIRCLE THOSE THAT APPLY) SELDOM, OCCASIONALY, FREQUENTLY, WITH VIGOROUS EXERCISE,
WITH HEAVY LIFTING
24) HAVE YOU INJURED YOUR KNEE IN THE PAST 2 YEARS? YES NO
_____RIGHT OR _____LEFT
DATE
_________
25) HAVE YOU BEEN TOLD BY A DOCTOR OR ATHLETIC TRAINER THAT YOU INJURED THE CARTILAGE IN YOUR KNEE? YES NO
_____RIGHT OR _____LEFT
DATE
26) HAVE YOU BEEN TOLD BY A DOCTOR OR ATHLETIC TRAINER THAT YOU INJURED THE LIGAMENTS IN YOUR KNEE? YES NO
_____RIGHT OR _____LEFT
DATE
27) HAVE YOU HAD KNEE SURGERY? YES NO _____RIGHT OR _____LEFT WHAT WAS DONE? ________________________DATE____________
28) HAVE YOU HAD A SEVERE ANKLE SPRAIN IN THE PAST 2 YEARS?
YES NO
_____RIGHT OR _____LEFT
DATE_______
29) DO YOU HAVE A PIN, SCREW, OR PLATE IN YOUR BODY? YES NO LOCATED WHERE
________________DATE
30) DO YOU HAVE OTHER CONDITIONS THAT WE SHOULD BE AWARE OF (I.E. ULCERS, PREGNANCY, FOOD OR INSECT ALLERGIES,
TENDINITIS, ETC)? YES NO (SPECIFY & GIVE DETAILS)
_________
31) DATE OF LAST IMMUNIZATION: _______TETANUS _______POLIO _______MUMPS _______RUBELLA ________MEASLES
THE QUESTIONS ON THIS FORM HAVE BEEN ANSWERED COMPLETELY AND TRUTHFULLY TO THE BEST OF MY KNOWLEDGE.
PARENT/GUARDIAN SIGNATURE
DATE
ATHLETE’S SIGNATURE
DATE
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